Discussion
Due to the simultaneous importance and challenge of parent-child
communication in childhood cancer, research is needed to better
understand how time affects the quality of communication between parents
and children with cancer. Novel aspects of this study included the
analyses of parent-child communication from both parent and child
perspectives, while prior studies have evaluated communication based on
either parent or child report.28,29 Other strengths of
the study included the large sample size and inclusion of patients with
relapsed/refractory cancer, a population that is typically difficult to
access.
Contrary to our hypothesis, increased time since cancer diagnosis was
associated with more problematic communication and worse overall
communication based on parent reports. These results align with those of
prior studies in pediatric cancer survivors that showed more time from
diagnosis increased the likelihood of developing a struggling
parent-child relationship with poor communication.29Similarly, children newly diagnosed with non-advanced cancer have shown
an increase in parent-child conflict and problematic communication over
time.28,30 While more parent-child communication
problems over time may be expected as children enter adolescence and
strive for more autonomy,31 we conducted a post-hoc
analysis that showed no statistically significant association between
child age and years since diagnosis. Thus, age is an unlikely mediator
of the correlation between time and problematic communication.
Our results also suggested that time from diagnosis did not impact
communication openness. This is in contrast to previous findings in
pediatric cancer patients, which showed a decrease in paternal openness
at one year after diagnosis compared to time of diagnosis in children
with non-advanced cancer.28 However, in studies
evaluating quality of communication between adults with cancer and their
adolescent children, parent-child communication openness and problems
were not impacted by time since diagnosis.32,33
Interesting to note is that our results showed no statistically
significant association between time from most recent relapse and
quality of communication in the patients with relapsed disease. These
results are congruent with a prior study, which showed that parent-child
communication problems and openness were more stable in children with
advanced cancer, measured in the year following relapse, than in healthy
children or those with newly diagnosed non-advanced
cancer.28 Ethnographic data from families who
experienced childhood cancer relapse found that families strive to
maintain normalcy and avoid letting cancer dominate their lives after
relapse, distinct from the new-diagnosis period when the families’ lives
are completely centered around the child’s
treatment.34 This may explain why relapse appeared to
be a less important milestone than diagnosis in affecting parent-child
communication. While disease relapse has been associated with a closer,
more involved parent-child relationship,29 with few
studies evaluating communication change over time, more research is
needed to understand the continued impact of relapse on parent-child
communication.
Limitations of our study included potential selection bias based on the
opt-in recruitment approach. The limited range of scores of the PACS may
have reduced the ability to detect correlations with time. A small
number of fathers participated (n = 10; 7.7%) as primary parent
caregivers; thus, the parent PACS data is biased towards maternal
impressions of communication with the ill child. Only 61% of children
completed the PACS about their fathers (versus 98% about their
mothers); this could be due in part to participation by single-parent
families, as half of participating parents report being married.
Regardless, limited father participation in pediatric research studies
has been a long-standing challenge.35–37 Social media
advertisements targeting fathers rather than gender-neutral “parent”
strategies have recently been shown to improve recruitment in this
population.38 Additional research on and
implementation of paternal recruitment strategies may allow for a more
balanced representation of parental perspectives in future studies.