
==== Front
101186624
30479
Pediatr Blood Cancer
Pediatr Blood Cancer
Pediatric blood & cancer
1545-5009
1545-5017

38644596
10.1002/pbc.31001
nihpa2015995
Article
Impact of sociodemographic factors, stress, and communication on health-related quality of life in survivors of pediatric cancer
http://orcid.org/0009-0007-3608-1331
Patterson Valdeoso 12
http://orcid.org/0000-0001-7037-2510
Olsavsky Anna 1
Garcia Dana 1
Sutherland-Foggio Malcolm 1
Vannatta Kathryn 12
Prussien Kemar V. 34
Bemis Heather 35
Compas Bruce E. 3
Gerhardt Cynthia A. 12
1 The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
2 The Ohio State University, Columbus, Ohio, USA
3 Vanderbilt University, Nashville, Tennessee, USA
4 Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
5 Children’s Hospital Los Angeles, Los Angeles, California, USA
Correspondence Valdeoso Patterson, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205, USA. patterson.933@osu.edu
23 8 2024
7 2024
21 4 2024
04 9 2024
71 7 e31001e31001
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Background:

While most research has largely focused on medical risks associated with reduced health-related quality of life (HRQOL) in survivors, sociodemographic and family factors may also play a role. Thus, we longitudinally examined sociodemographic factors and family factors associated with survivor HRQOL, including adolescent’s cancer-specific stress, mother’s general stress, and mother–adolescent communication.

Methods:

Mothers (N = 80) and survivors (ages 10–23, N = 50) were assessed 5 years following initial diagnosis. Mothers completed measures regarding sociodemographic background adolescent’s cancer-specific stress, mother’s general stress, mother–adolescent communication, and adolescent HRQOL. Survivors also reported on their own HRQOL. Two hierarchical multiple regressions examined predictors of (a) mother’s report of adolescent HRQOL, and (b) survivor’s self-report of HRQOL.

Results:

The final model predicting mother-reported adolescent HRQOL was significant, F(5,74) = 21.18, p< .001, and explained 59% of the variance in HRQoL. Significant predictors included adolescent stress (β = −.37, p< .001), mothers’ stress (β = −.42, p< .001), and communication (β = .19, p = .03). The final model predicting survivor-reported HRQOL was also significant, F(5,44) = 5.16, p< .01 and explained 24% of the variance in HRQOL. Significant predictors included adolescent stress (β = −.37, p = .01) and communication (β = −.31, p = .04). Sociodemographic factors were not a significant predictor of HRQOL in any model.

Conclusion:

Family stress and communication offer potential points of intervention to improve HRQOL of pediatric cancer survivors from mother and survivor perspectives. While additional research is needed, healthcare professionals should encourage stress management and strong mother–child communication to enhance survivors’ long-term HRQOL. Such interventions may be complimentary to efforts targeting the known sociodemographic factors that often affect health.

cancer survivorship
communication
family stress
health-related quality of life
sociodemographic risk
==== Body
pmc1 | INTRODUCTION

Despite successful efforts to improve survival and reduce morbidity over the past several decades, pediatric cancer remains a significant stressor for families.1 Although the diagnosis can result in significant family burden, the severity of that burden can depend, in part, on the family’s sociodemographic background.2 For example, income, parent education, and household size can determine a family’s ability to cover the costs of treatment, travel to the hospital, and manage complex regimens at home.2 These factors can also determine the capacity of caregivers to balance work and caregiving demands, resulting in risk for financial toxicity.3 Furthermore, pre-existing sociodemographic and family stressors may be simultaneously exacerbated by cancer-related stress, affecting how well families manage the burdens of the disease. Compared to children from healthy populations, children on treatment for cancer often experience significant impairment in health-related quality of life (HRQOL),4 which incorporates functioning in emotional, physical, social, and academic domains.5 Thus, the family’s success in navigating the pediatric cancer experience may have significant implications for the child’s long-term HRQOL.

Although attention to social determinants of health has grown, few longitudinal studies in pediatric cancer have examined sociodemographic factors in combination with family factors to predict long-term HRQOL.6 Family stress models help to explain how social determinants and their accumulation can disrupt family functioning to influence child health outcomes.7,8 Thus, the combination of these factors may predispose certain survivors for poor HRQOL long-term. Among survivors of childhood cancer, several individual factors, such as female sex, older age, less education, lower socioeconomic status, and minority status, have been associated with lower HRQOL.9–11 Another study focused on children with advanced cancer found that those from low-income families experienced a higher prevalence of pain, more distress, and worse HRQOL compared to children from high-income families.12 Similar cross-sectional work has examined sociodemographic factors associated with family stress in pediatric cancer populations. For example, one study showed that at the bivariate level, sociodemographic factors (i.e., single parenthood, family income, education level, and race) were significantly associated with some, but not all, indicators of mothers’ general stress and children’s cancer-specific stress and distress near diagnosis.2

Parents of cancer survivors can face a multitude of stressors including relapse, secondary effects of illness and treatment, continued costs, or supporting siblings. One study showed that mothers of children on treatment had higher levels of perceived stress and a less positive image of themselves as parents than mothers of healthy children.13 Children also report significant stress during treatment, such as disruptions in daily/role functioning, physical effects of treatment, uncertainty about the disease, and fears about death.14,15 Specifically, children find impairment in daily/role functioning (e.g., not being able to do the things they used to do) more stressful than uncertainty about their disease or chances for survival.14 Thus, when examining predictors of HRQOL in pediatric cancer survivors, it is important to consider both parental and child experiences of cancer-related stress, in addition to cumulative sociodemographic and pre-existing family stress.

Cancer also creates demands relative to supportive communication between parents and their child. Over the past 30 years, there has been a shift from avoidance of communication about pediatric cancer to an emphasis on parents and children having straightforward discussions about diagnosis and prognosis.16 Communication, more broadly, is an important aspect of the parent–child relationship that demonstrates the level of trust, intimacy, and conflict between the two, while setting the stage for how families navigate this challenge.17 For example, relative to healthy controls, mothers’ openness and problems in general communication may be similar over the first year after diagnosis or relapse regardless of whether children had advanced or non-advanced cancer.18 One study found that childhood cancer survivors who reported better quality relationships with their mothers and fathers consistently reported better HRQOL,19 while research in other pediatric populations has linked general parent–child communication with both child adjustment and adherence.20–22

Despite the literature demonstrating the respective impact on HRQOL from sociodemographic factors, parent and child stress, and parent–child communication, no studies to date have prospectively examined the combined effects of these factors on the long-term HRQOL of pediatric cancer survivors. The present research examines associations between early sociodemographic (e.g., mother age, mother education, family income, number of children, number of parents, and race), family stress (i.e., mother’s general stress, adolescent’s cancer-specific stress), and general mother–adolescent communication on the HRQOL of survivors at 5 years post diagnosis. We hypothesized that higher levels of cumulative sociodemographic risk, mother’s general stress, adolescent’s cancer-specific stress, and lower quality of general mother–adolescent communication near diagnosis would predict lower HRQOL for survivors 5 years later.

2 | METHODS

2.1 | Procedure

Following approval from the Institutional Review Board (IRB #041135), eligible participants were selected from cancer registries and recruited by research staff at two large pediatric hospitals in the United States (one in the Midwest, one in the Southeast). Participants were recruited following either an initial cancer diagnosis or relapse. Parents were provided with information about the study and gave their written consent for participation. Children also gave their written consent or assent (for ages 10–17). Paper and pencil surveys were then completed at their convenience. After finishing the surveys at enrollment (T1), families were contacted for follow-up assessments at 1 (T2), 3 (T3), and 5 years (T4) later.23

2.2 | Participants

Eligible children (a) had a primary cancer diagnosis or new recurrence of cancer, (b) were aged between 5 and 17 at recruitment, and (c) were fluent in English (including parents). Children and parents were ineligible if they had a pre-existing neurodevelopmental disorder or disability that precluded completing measures. At enrollment, 336 families participated.

At 5-year follow-up, 18% (n = 59) of children from enrollment were deceased.23 Of 277 approached families, 45% (n = 124) participated. For the current manuscript, the final sample included only mothers (N = 80) and children (N = 50), who completed mother proxy-reported HRQOL and adolescent self-reported HRQOL at 5-year follow-up.

2.3 | Measures

2.3.1 | Demographic questionnaire

Family demographic characteristics were provided by parents using a questionnaire that assessed factors such as marital status, education, occupation, religious beliefs, income, and number and age of children at enrollment (T1). Similar to previous work in a pediatric cancer sample, a cumulative sociodemographic score was calculated.2 Each sociodemographic variable of interest was dichotomized as 0 or 1 to indicate lesser or greater risk.2 The scoring was as follows: multi-adult (0) versus single adult (1) household status income greater than $50,000 (0) versus income ≤$50,000 (1), mother education higher than 12th grade (0) versus mother education ≤12th grade (1), White race (0) versus non-White race (1), and zero to two children living in the household (0) versus three or more children living in the household (1).

2.3.2 | Perceived stress scale (PSS)

This widely used 10-item instrument assesses subjective experiences of psychological stress.2,23 Mothers rated each item on a four-point scale of how often each item was true for them within the past month.2 Internal consistency, test–retest ability, and concurrent and predictive validity have all been established.24 Internal consistency in the current sample was low, α = .55.

2.3.3 | Responses to Stress Questionnaire - Pediatric Cancer Version (RSQ-PC)

The RSQ-PC is a 57-item measure that includes a list of 11 cancer-related stressors (e.g., missing school, frequent hospital or clinic visits, changes in personal appearance) using a four-point scale ranking items from “Not at all” to “Very.”25 Mothers provided proxy-report on their children. Prorated mean scores were calculated for overall cancer-related stress. The RSQ-PC has been used extensively with acceptable reliability and validity.26–28 Internal consistency in this sample was high, α = .92.

2.3.4 | Parent–adolescent communication scale (PACS)

This questionnaire includes 20-items rated 1–5 regarding the quality of general communication between parents and their adolescents.23 The measure has been used widely with youth as young as 8 years old and includes two subscales: (a) Open Family Communication, and (b) Problems in Family Communication. A total communication score is calculated by coding the Open Family Communication subscale so that higher scores indicate more openness, and reverse coding the Problems in Family Communication subscale so that higher scores indicate fewer problems in parent–adolescent communication.29 The scales demonstrate internal consistency and adequate 4-week test–retest reliability.23 Mothers’ provided self-report of communication with their adolescent (ages 10+). Internal consistency in the current sample was acceptable, α = .70.

2.3.5 | Pediatric Quality of Life Inventory Version 4.0 (PedsQL)

The PedsQL 4.0 is an established measure of HRQOL and includes 23 items across four subscales: physical, emotional, social, and school functioning.30 Items are reverse-coded and linearly transformed to a scale of 0–100, with higher scores indicating better HRQOL. Parents provided proxy-report of their child’s HRQOL, and survivors provided self-report. One version was used for children ages 8–12 years, and another was used for children ages 13–18 years. The PedsQL has been used extensively to evaluate the HRQOL of children with chronic health problems.30 The reliability and validity of this instrument have been established in previous work for youth of ages 5–18.31,32 Internal consistencies in the current sample were α = .89 for mother proxy-report, and α = .88 for child self-report, which are deemed good.

For the current manuscript, each measure was administered at enrollment, except the PedsQL, which was administered at 5-year follow-up. Mothers completed all measures, and adolescents completed only the PedsQL.

2.4 | Analysis plan

Analyses were conducted using SPSS (v.26). Descriptive statistics were conducted to examine the frequencies, mean, and standard deviation of sociodemographic factors, cancer-specific stress, general stress, parent–adolescent communication, and HRQOL. Bivariate correlations were conducted to examine associations between the cumulative sociodemographic score, mother’s general stress, adolescent’s cancer-related stress, mother–adolescent communication, and survivor HRQOL (mother proxy-report and child self-report) at 5 years post diagnosis (Table 1). Based on bivariate correlations, two hierarchical regressions were used to examine predictors of (a) mother’s proxy-report of survivor HRQOL, and (b) survivor’s self-report of HRQOL. In Step 1, only mother’s age and the sociodemographic score were included. Step 2 included adolescent’s cancer-specific stress and mother’s general stress. Lastly, Step 3 added mother–adolescent communication. Although our focus was on the potential cumulative effects of predisposing factors near enrollment, alternative models examining individual sociodemographic factors were also tested.

3 | RESULTS

3.1 | Sample characteristics

Table 1 summarizes descriptive information for mother and child factors, as well as the predictor and outcome variables. Most mothers were on average 37.83 years old (SD = 7.59), White (n = 69; 86%), partnered (n = 59; 74%), and had completed at least a high school diploma (n = 65; 81%). The number of families making above (n = 41; 51%) or below $50,000 per year (n = 39; 49%) was similar. Survivors were on average 15.43 years old (SD = 3.87) at T4 and mostly male (n = 41; 51%). A large portion of survivors were diagnosed with either leukemia (n = 32; 40%) or other solid tumors (n = 28; 35%), and on average had been off treatment for 3.61 years (SD = 1.23). Attrition analyses indicated that mothers and survivors who did and did not participate were similar in background and medical variables: child sex, χ2(1, 249) = .02, p = .88; White versus non-White race, χ2(1, 246) = .32, p = .57; family income, χ2(1, 241) = 1.04, p = .15; single parent household, χ2(1, 247) = .97, p = .32; χ2(1, 249) = .02, p = .88; diagnosis types (i.e., leukemia, lymphoma, brain tumor, other solid tumor), χ2(3, 259) = 2.34, p = .51; mother education, χ2(1, 246) = 2.47, p = .12; three or more children in household, χ2(1, 243) = 2.65, p = .10). However, mothers and survivors in this sample had significantly lower treatment intensity at T1 compared to those who did not complete 5-year follow-up, t(164) = 2.34, p = .02.

3.2 | Descriptive statistics and correlations among variables of interest

Mean HRQOL scores based on mother proxy-report (M = 79.84; SD = 14.61) and survivor-report (M = 83.14; SD = 13.30) were in the normal range and above clinical cutoff scores (65.4 and 69.7, respectively).24 Mean scores for remaining variables of interest were 19.20 (SD = 7.50) for adolescent cancer-specific stress, 15.93 (SD = 7.09) for mothers’ general stress, and 80.18 (SD = 8.55) for mother–adolescent communication. Initial examination of associations between demographic/medical factors (i.e., sociodemographic score, survivor age, survivor sex, mother’s age, time since treatment) and HRQOL revealed one significant correlation between the sociodemographic score and mother-reported survivor HRQOL (see Table 2). Other variables of interest, including mother-reported survivor cancer-specific stress, mother’s general stress, and parent–adolescent communication showed significant bivariate correlations with mother-reported survivor HRQOL. Analyses also revealed a significant correlation between survivor-reported HRQOL and mother report of survivor’s cancer-specific stress. Of note, mother’s age was included as a covariate in models, given its significant correlations with cumulative risk and general stress.

3.3 | Longitudinal predictors of mother-reported survivor HRQOL

A hierarchical regression model examined baseline predictors of mother-report of survivor HRQOL at 5-year follow-up. The first step examined mother’s age and the sociodemographic score. This model was significant, F(2,77) = 8.38, p < .001, and explained 18% of the variance in HRQOL. The sociodemographic score was the sole significant predictor (β =−.39, p < .001). The second step added mother-report of survivor’s cancer-specific stress and mother’s general stress, which contributed an additional 38% of explained variance in HRQOL, ΔF(2,75) = 32.81, p < .001. Both mother-report of survivor’s cancer-specific stress (β = −.39, p < .001) and mother’s general stress (β =−.46, p < .001) were significant predictors of HRQOL, but the sociodemographic score was no longer a significant predictor. Finally, mother–adolescent communication was added in the third step of the model, and contributed an additional 3% of variance in HRQOL, ΔF(1,74) = 5.26, p = .03. This final model was significant, F(5,74) = 21.18, p < .001, and explained 59% of the total variance. With the addition of mother–adolescent communication, survivor’s stress (β =−.37, p < .001), mother’s stress (β =−.42, p < .001), and communication (β = .19, p = .03) were all significant predictors of HRQOL (Table 3). Of note, alternate models including individual sociodemographic factors indicated that these variables did not contribute unique variance in the final step.

3.4 | Longitudinal predictors of survivor-reported HRQOL

A second hierarchical regression model examined predictors of survivor-reported HRQOL using the same variables in the first model. In the first step, we examined mother’s age and the sociodemographic score. This model was not significant, F(2,47) = 0.70, p = .504, as it only explained 3% of the variance in HRQOL. In the second step, mother-report of survivor’s cancer-specific stress and mother’s general stress were added. This model was significant, ΔF(2,45) = 3.50, p = .039, and added 13% of explained variance. Only mother-report of survivor’s cancer-specific stress (β = −.56, p = .022) was a significant predictor. In the third and final step, mother–adolescent communication was added and contributed 8% of explained variance to the model, ΔF(1,44) = 4.37, p = .042. With the addition of mother–adolescent communication, survivor’s cancer-related stress (β = −.37, p = .011) and communication (β =−.31, p = .042) were significant predictors of survivor-reported HRQOL. This final model was significant as well, F(5,44) = 2.71, p = .032, and explained 24% of the variance in the long-term HRQOL of survivors (Table 3). Of note, alternate models including individual sociodemographic factors indicated that only mother’s income contributed unique variance (β = .30, p = .031) in the final step.

4 | DISCUSSION

Limited research has examined early sociodemographic and family factors near diagnosis that predict long-term HRQOL among childhood cancer survivors. The goal of this study was to examine the relative impact of sociodemographic factors using a cumulative risk score, mother’s stress, survivor’s cancer-specific stress, and mother–adolescent communication on later HRQOL of survivors. We expected that a higher cumulative sociodemographic score (i.e., higher risk) would lead to lower levels of HRQOL in survivors. Survivor HRQOL was, on average, in the normative range at 5-year follow-up. Contrary to our hypothesis, the sociodemographic score was not a significant predictor of HRQOL when other factors like cancer-related stress and communication were considered. While these results did not align with our expectations for the sociodemographic score, they demonstrate the lasting importance of more proximal family factors in relation to later HRQOL in long-term survivors.

In both the mother-reported model and the survivor-reported model, earlier exposure to stress consistently predicted long-term HRQOL, whether it was survivor’s cancer-specific stress or mother’s general stress. The mother-reported model explained almost 60% of the variance in survivor HRQOL, with survivor’s cancer-specific stress and mother’s general stress contributing 38% of explained variance in the model. These results support our hypothesis about stress, and are consistent with literature finding that stress and negative emotions in response to a chronic illness, such as cancer, can affect HRQOL.33 For survivor-report of HRQOL, the addition of survivor’s cancer-specific stress and mother’s general stress contributed 13% of explained variance in HRQOL, with the overall model explaining 24% of the variance in long-term HRQOL. However, only cancer-specific stress was a significant predictor. Thus, survivors’ HRQOL may be affected more by their own stress specifically related to their diagnosis, than their mother’s general stress. To our knowledge, this is the first study that has examined the longitudinal impact of general and cancer-related stress on survivor-reported HRQOL in a pediatric cancer sample.

In both models, higher quality of mother–adolescent communication was a significant predictor of better HRQOL, particularly with respect to child-report of HRQOL. These results support our hypothesis that communication has a significant impact on survivors’ HRQOL. Previous research in pediatric populations has found that a high quality of family communication enhanced adolescents’ life satisfaction.34 Other studies have also identified family communication as a correlate of important developmental, psychosocial, and health outcomes.20,35,36 In previous findings from our study, openness and problems in mother–child communication did not differ between those with advanced or non-advanced cancer at enrollment compared to healthy controls.18 However, quality of communication was predictive of distress 1 year later, but only for children with advanced disease. This suggests unique associations for communication potentially based on timing since diagnosis, severity of cancer, and psychosocial outcome.

While research has largely focused on medical predictors of HRQOL in pediatric cancer, few studies have examined the longitudinal impact of family factors near diagnosis, such as stress and communication, on later HRQOL. Previous findings from this sample indicated that time since treatment, child sex, and central nervous system (CNS)-directed treatment were related to long-term HRQOL.30 However, current results also show that family factors should not be overlooked. Both stress and communication were associated with HRQOL and were significant predictors over time. Although cumulative sociodemographic factors did not predict long-term HRQOL in our final models, they were significantly correlated with mother-reported HRQOL. Similar to previous findings,2 the cumulative sociodemographic score was also significantly correlated with mother’s general stress, adolescent’s cancer-specific stress, and mother–adolescent communication near diagnosis. Therefore, future research should continue to examine the role of sociodemographic factors and survivorship outcomes, such as HRQOL, over time.

Our study was limited by several factors. First, our sample was primarily White and non-Hispanic. Similar research should be conducted with a more diverse sample to examine if associations may vary as a function of race or ethnicity in regard to sociodemographic factors and HRQOL. We also examined only survivor-report and mother-report of family factors. Future research should solicit perspectives from others close to the survivor, such as fathers, siblings, peers, and partners, to reduce shared method variance. Importantly, the mother-proxy model may have been affected by common method variance, and multiple informants are necessary to test more robust models. Lastly, our sample comprised mothers who were largely partnered, had few children per household, and had an education of at least a high school diploma, resulting in a relatively low-risk sample. This could have explained why the cumulative sociodemographic score was no longer a factor when stress and communication were examined concurrently. Future research should continue to identify other social and family factors early in the cancer trajectory that may influence the long-term HRQOL of pediatric cancer survivors also. In addition, it is important to explore other associations, including potential interactions between social and family factors, in relation to long-term HRQOL.

Our study also had several key strengths. First, the sample was recruited soon after a child was diagnosed with cancer or had relapsed and was followed longitudinally over 5 years. This allowed us to identify early predictors of later outcomes in long-term survivorship. Second, the sample was inclusive in terms of different diagnoses, allowing us to examine HRQOL in children affected by pediatric cancer more broadly, rather than focusing on one type of diagnosis. This research is unique in its family-centered approach assessing both general stress and cancer-specific stress, as well as multiple viewpoints (parent self-report, parent proxy-report of survivor, survivor self-report). Limited research has examined the contributions of sociodemographic and family factors that predict HRQOL in youth affected by pediatric cancer.

This information can help inform family-centered care to improve long-term HRQOL in pediatric cancer survivors. Despite the effects of cumulative sociodemographic risk, family stress and communication may offer potential points of intervention to improve HRQOL of pediatric cancer survivors over time. Clinicians should assess family- and cancer-related stress, as well as facilitate open and honest parent–child communication early in treatment to reduce risks. Previous psychosocial interventions have shown promise in the areas of physical, psychological, and social-relational aspects of HRQOL.37,38 Early coping and communication training might augment existing interventions or inform new approaches to support the well-being of survivors. This can include aiding difficult conversations among family members as the child’s health declines.18 Given the multifaceted and multi-determined nature of HRQOL, multi-systemic interventions may be required over time. While additional research is needed, healthcare professionals should encourage stress management and strong mother–child communication to enhance survivors’ long-term HRQOL. Such strategies may be helpful, irrespective of known sociodemographic risk factors that often affect health.

ACKNOWLEDGMENTS

We would like to thank the families who generously participated in this work. Funding was provided by the National Cancer Institute (R01 CA118332, R01 CA248103–01A1S2) and the Abigail Wexner Research Institute at Nationwide Children’s Hospital.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Abbreviations:

HRQoL health-related quality of life

PACS parent–adolescent communication scale

PedsQL Pediatric Quality of Life Inventory Version 4.0

RSQ-PC Responses to Stress Questionnaire - Pediatric Cancer Version

TABLE 1 Sample characteristics of participants.

	M (SD)	N (%)	
	
Mother factors			
Age	37.83 (7.59)	–	
Income (<$50,000)	–	39 (49%)	
Single	–	21 (26%)	
Education (≤12th)	–	15 (19%)	
Children (≥3)	–	30 (38%)	
Race (non-White)	–	11 (14%)	
Child factors			
Gender (male)	–	41 (51%)	
Age at diagnosis	9.68 (3.75)	–	
Age at 5-year follow-up	15.43 (3.87)	–	
Time since Tx (years)	3.61 (1.23)	–	
Leukemia		32 (40%)	
Lymphoma		14 (18%)	
Brain tumor		5 (6%)	
Other solid tumor		28 (35%)	
Family factors			
Adolescent’s cancer-specific stress	19.20 (7.50)	–	
Mother’s general stress	15.93 (7.09)	–	
Mother-adolescent communication	80.18 (8.55)	–	
Health-related quality of life			
Mother-reported PHRQoL	79.84 (14.61)	–	
Adolescent-reported PHRQoL	83.14 (13.30)	–	
Abbreviations: PHRQoL, pediatric health-related quality of life; Tx, treatment.

TABLE 2 Pearson correlations among variables of interest.

Measure	1	2	3	4	5	6	7	8	9	10	11	12	13	14		
	
1. Cum. risk	–															
2. Child age	−.18	–														
3. Child sex	.09	.03	–													
4. Mother’s age	−.40**	.64**	.05	–												
5.Time since Tx	−.01	.20	.34*	.17	–											
6. RSQ-PC	.33**	−.09	−.05	−.18	−.03	–										
7. PSS	.34**	−.15	.01	−.25*	−.13	.40**	–									
8. PACS	−.32**	−.04	−.01	.18	.02	−.29**	−.31**	–								
9. M PHRQoL	−.42**	.05	.00	.23	.24	−.51**	−.62**	.43**	–							
10. C PHRQoL	−.15	.13	−.21	.13	.08	−.43**	−.22	−.13	.48**	–						
11. Low income	.57**	−.21	.17	−.35**	.14	.28*	.39**	−.17	−.35**	−.38**	–					
12. Low mother education	.43**	.10	.14	−.06	.03	.08	.18	−.13	−.19	.002	.28*	–				
13. Single parent	.55**	−.05	.17	−.21	.03	.24*	.35**	−.34**	−.45**	−.21	.41**	.19	–			
14. Non-White	.41**	−.24	−.17	−.08	.10	.12	.12	−.05	−.07	−.03	.26*	−.07	.05	–		
15. ≥3 Children	.16	.12	−.01	−.02	−.28	.05	.20	−.04	−.05	−.08	−.10	−.02	−.04	.04		
Abbreviations: C PHRQOL, child-reported pediatric health-related quality of life; Cum., cumulative; Low income, income ≤$50,000; Low mother education, mother education ≤12th grade; M PHRQOL, mother-reported pediatric health-related quality of life; PACS, parent-adolescent communication scale; PSS, perceived stress scale; RSQ-PC, Responses to Stress Questionnaire - Pediatric Cancer; Tx, treatment; ≥3 Children, 3 or more children living in the household.

* p < .05.

** p < .01.

TABLE 3 Hierarchical regressions examining longitudinal predictors of mother-reported and adolescent-reported survivor health-related quality of life.

	Mother-reported HRQoL	Survivor-reported HRQoL	
Variables	B (SE)	β	p	B (SE)	β	p	
	
1							
 Constant	81.71 (10.18)		<.001	78.97 (12.09)		<.001	
 Mother’s age	0.12 (0.21)	.07	.456	0.14 (0.26)	.09	.58	
 Cum. risk	−4.97 (1.41)	−.39	<.001	−1.26 (1.58)	−.12	.43	
	F = 8.38**			F = 0.70			
	R2 = .18			R2 = .03			
2	
 Constant	110.43 (8.37)		<.001	93.22 (11.05)		<.001	
 Mother’s age	0.04 (0.16)	.02	.81	0.24 (0.22)	.14	.29	
 Cum. risk	−1.83 (1.17)	−.15	.11	−0.82 (1.46)	−.08	.59	
 RSQ-PC	−0.75 (0.16)	−.39	<.001	−1.00 (0.23)	−.56	<.001	
 PSS	−0.95 (0.17)	−.46	<.001	−0.03 (0.25)	−.02	.90	
	F = 23.81**	ΔF = 32.41**		F = 5.85**	ΔF = 10.72**		
	R2 = .56	ΔR2 = .38		R2 = .34	ΔR2 = .31		
3	
 Constant	82.80 (14.54)		<.001	118.90 (21.52)		<.001	
 Mother’s age	0.03 (0.16)	.01	.87	0.19 (0.22)	.11	.39	
 Cum. risk	−1.34 (1.11)	−.11	.23	−0.98 (1.45)	−.09	.50	
 RSQ-PC	−0.71 (0.16)	−.37	<.001	−0.96 (0.23)	−.53	<.001	
 PSS	−0.87 (0.17)	−.42	<.001	−0.18 (0.27)	−.10	.51	
 PACS	0.32 (0.14)	.19	.03	−0.28 (0.20)	−.19	.17	
	F = 21.18**	ΔF = 5.26**		F = 5.16**	ΔF = 1.92		
	R2 = .59	ΔR2 = .03		R2 = .37	ΔR2 = .03		
Abbreviations: Cum., cumulative; PACS, parent–adolescent communication scale; PSS, perceived stress scale; RSQ-PC, Responses to Stress Questionnaire - Pediatric Cancer.

* p < .05.

** p < .01.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no conflicts of interest.

Portions of this work were presented at the Pediatric Academic Society 2019 Meeting in Baltimore, MD, USA.
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