Research examining the physical, social, and emotional consequences of pediatric cancer and its treatment highlights the significant impact on health-related quality of life (QOL) [1
]. The preponderance of research on QOL in pediatric cancer focuses on survivors of cancer and young children on treatment. How cancer diagnosis and treatment stressors specifically affect adolescents is not well understood. Adolescence is typically a period of rapid physical, cognitive and psychosocial change that takes place in the context of shifting relationships and roles within the family [4
]. Cancer and associated teen and family stressors may challenge adolescent QOL through their impact on normative adolescent developmental tasks (e.g., ability to attend school, engage in activities with peers, participate in extracurricular activities, take on greater responsibilities within their families, in their schools and in their communities) [5
]. Adolescents with cancer have been identified as being at greater risk than their younger counterparts up to 15 months post-diagnosis, highlighting the importance of examining QOL in adolescents with cancer [5
]. Because little is known about family factors that impact the QOL of adolescents with cancer receiving treatment, this study explores the contribution of family sociodemographic risk and family resources, in addition to treatment intensity.
Characteristics of cancer and treatment including type of diagnosis (particularly those that affect the central nervous system; [7
]), intensity of treatment [3
], and phase of treatment [9
] have been associated with QOL for children and adolescents. For example, Landolt and colleagues [1
] determined that QOL significantly decreases during treatment for childhood cancer, but most aspects of QOL improve as children move off treatment. Wu and colleagues [10
] similarly found that adolescents on treatment were more likely to report poorer QOL than those off treatment. Importantly, regardless of phase of treatment, QOL is significantly associated with intensity of treatment and presence of medical complications. Speechley and colleagues [3
] found that QOL was associated with type of cancer and treatment received. Cranial radiation, in particular, contributed most to deficits in QOL.
While treatment characteristics are central to QOL, cancer is treated in the context of the family [11
] and models linking family risks and resources to health and psychosocial outcomes for youth with chronic conditions have been described. For example, the Family Adjustment and Adaptation Response (FAAR) model highlights how adaptation to chronic childhood illness is explained in the balance of family demands (stressors from individual, family, and community sources) as well as family resources such as positive parent-child relationships, family functioning, and active coping and positive beliefs/attitudes [12
]. Integrating family functioning with disease characteristics, intrapersonal variables, and psychosocial factors, the risk-and-resistance model posits an interaction of risks and resources in explaining adaptation to chronic conditions of childhood including QOL [13
Specific risk factors that may be associated with poorer QOL for children and adolescents with cancer include family sociodemographic characteristics related to limited resources and increased stressors (such as parent education, family income, family structure, family size, and ethnic minority status). Risk for adverse health status is greatest among patients with childhood cancer on and off treatment that are female, of low educational level, with low household incomes, and of ethnic minority status [8
]. Moore, Vandivere, and Redd [17
] argue for the value of assessing cumulative sociodemographic risk as it can serve as a summary indicator of the multifaceted environments in which children develop.
Conversely, general family functioning may promote positive outcomes for children undergoing stressful circumstances, and family support has been shown to be a vital resource for children and adolescents with cancer [11
]. Orbuch and colleagues [18
] examined parent-child relationships and QOL among childhood cancer survivors, focusing on the association between survivors' evaluations of parent-child relations and self-reported QOL. Survivors who reported quality relationships with their mothers and fathers consistently reported a better QOL, especially within the psychological domain. Similarly, Vance and colleagues [20
] found that children who self-reported poorer QOL had mothers who endorsed more symptoms of depression and illness-related stressors. Moreover, Eiser, Eiser, and Greco [21
] identified that teens with cancer reported better QOL when their parents remained goal-focused instead of protective in their parenting. In many cases, however, parents exhibit greater levels of distress than their children with cancer creating family burden [2
], and families of children and adolescents with cancer rate themselves as less cohesive and more conflicted than do families of healthy children [23
]. Thus, the role of positive parent-child relationships and family functioning may be potential sources of resilience, fostering better QOL outcomes for adolescents with cancer [11
Despite considerable research describing QOL of patients with childhood cancer both on and off treatment, studies have rarely targeted adolescents or examined the relative contribution of treatment intensity, family sociodemographic risk, and family resources. Therefore, the goal of this study was to evaluate the relative contribution of treatment intensity, family sociodemographic risk, and family resources to health-related quality of life of adolescents on treatment for cancer. Based on the pediatric cancer literature, we hypothesized adolescents with more intense treatments would report poorer QOL. Consistent with risk-and-resistance models, however, family sociodemographic risk factors and family resources (parent and teen reports of roles in family functioning and quality of parent-child relationships) were expected to significantly contribute to QOL. More specifically, sociodemographic risk factors were expected to be associated with poorer QOL, and adaptive family functioning and higher quality of the parent-child relationship were expected to be associated with better QOL among adolescents on treatment for cancer.