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 occur in any family, the resulting burdens 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. Thus, the family’s success in navigating the pediatric cancer experience may have significant implications for the child’s long-term quality of life (QOL).
QOL in childhood incorporates functioning in emotional, physical, social, and academic domains [4]. Children on treatment for cancer often experience significant impairment in QOL compared to children from healthy populations [5]. Although attention to social determinants of health have grown, limited research has examined sociodemographic factors in the context of pediatric cancer and long-term QOL. However, similar work has been conducted on stress as the outcome in pediatric cancer populations. 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’ and children’s stress and distress near diagnosis [2]. Another study found that children with advanced cancer from low-income families experienced a higher prevalence of pain and more distress compared with children from high-income families [6]. Children from low-income families also reported worse QOL [6].
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 [7]. 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 [8,9]. 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 [8]. Thus, when examining predictors of quality of life in pediatric cancer survivors, it is important to consider both parental and child experiences of cancer-related stress, in addition to sociodemographic background and pre-existing family stress.
Cancer also creates demands relative to supportive communication between parents and their child. Communication is an important aspect of the parent-child relationship that demonstrates the level of trust, intimacy, and conflict between the two [10]. 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 [11]. For example, relative to healthy controls, mothers’ openness and problems in communication may be similar over the first year after diagnosis or relapse regardless of whether children had advanced or non-advanced cancer [12]. One study found that childhood cancer survivors who reported better quality relationships with their mothers and fathers consistently reported better QOL [13], while research in other pediatric populations have linked parent-child communication with both child adjustment and adherence [14,15,16].
Despite the literature demonstrating the respective impact of sociodemographic factors, parent and child stress, and parent-child communication on quality of life, no studies to date have prospectively examined the combined effects of these factors on the long-term quality of life 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), mother–adolescent communication on the quality of life of survivors at five 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 mother-adolescent communication near diagnosis would predict lower quality of life for survivors five years later.