(2024) 24:531
Sudnawa et al. BMC Pediatrics
https://doi.org/10.1186/s12887-024-05010-8

BMC Pediatrics

RESEARCH

Open Access

Health‑related quality of life and its
determinant factors in Thai children with cancer:
parents vs. children perspectives
Khemika K. Sudnawa1 , Jitthip Yeepae2, Apichat Photia3 , Piya Rujkijyanont3 , Chanchai Traivaree3    andChalinee Monsereenusorn3*   

Abstract
Background Health-related quality of life (HRQOL) is a vital assessment to demonstrate the achievement in pediatriccancer care parallels that of medical treatment. The Pediatric Quality of Life Inventory (PedsQL) 3.0 Cancer Modulein the Thai Version has become a standard tool to access the HRQOL among Thai children with cancer and their families. This study aimed to explore the HRQOL and factors related to HRQOL among pediatric oncology patients using
the PedsQL 3.0 Cancer Module.
Methods In 2018–2019, a single-institution, cross-sectional study was conducted among children with cancer and their families in Bangkok, Thailand. A paired-sample t-test was performed to evaluate the differences
between the HRQOL scores of the child and parents’ reports. Linear regression was used to evaluate factors associatedwith HRQOL and which particular domains of the PedsQL 3.0 Cancer Module were influenced.
Results Eighty-five children with cancer and their families were enrolled. The patients’ mean age
was 10.82 ± 5.48 years. The most common cancer types included acute lymphoblastic leukemia (n = 32, 67%), central
nervous system tumors (n = 13, 15%), osteosarcoma (n = 10, 27%) and neuroblastoma (n = 9, 24%), in rank. The mean
HRQOL scores in child and parent reports were 74.37 ± 15.7 and 70.42 ± 17.15, respectively (p = 0.034). Factors negatively correlated to HRQOL in parent reports were the number of outpatient visits (p = 0.019) and hospital admissions(p = 0.002). The number of hospitalizations was the only independent factor that affected HRQOL (p = 0.044). The
number of outpatient visits and/or hospital admissions was influenced by pain and hurt, nausea, procedural anxiety
and communication domains (p < 0.05). Only the number of hospitalizations was an independent factor influencing
the procedural anxiety domain in HRQOL (p = 0.005).
Conclusion HRQOL among Thai children with cancer was desirable from both children’s and parent’s perspectives.
Differences between child and parent HRQOL scores were observed. The number of outpatient visits and hospital
admissions affected HRQOL, particularly in the procedural anxiety aspect.
Trial registration Thai Clinical Trials Registry (TCTR) Number: TCTR20200904001 (04/09/2020), https://​www.​thaic​linic​
altri​als.​org/.
Keywords Health-related quality of life, Children with cancer, Thailand, Parents, Factors*Correspondence:
Chalinee Monsereenusorn
chalinee_monsereenusorn@pedpmk.org
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as longas you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article orparts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicatedotherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not
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view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Sudnawa et al. BMC Pediatrics(2024) 24:531

Introduction
Childhood cancer is one of the major public healthproblems, with an overall incidence rate of 140.6 per
million person-years globally [1]. Different types ofcancer require specific treatment plans according to thedisease and its severity. The wide range of treatment
modalities includes systemic chemotherapy, surgery,radiation, immunotherapy and hematopoietic stem celltransplantation. Although the increased survival rateof up to 80% [2] underlines the success of advanced
medical care for devastating diseases, cancer treatment
among children remains a major physical and psychological stressor for both patients and families.
The World Health Organization (WHO) defines
health, “as a state of complete physical, mental andsocial well-being, not merely the absence of diseaseor infirmity” [3]. Therefore, measuring health with thepresence or absence of diseases remains insufficient.
Physical and biochemical measurements may indicate
only disease and treatment strategies. However, these
do not demonstrate the patient’s well-being and mental health, which should be considered as an important
health dimension called the quality of a person’s life.
Quality of life (QOL) constitutes “an overall senseof well-being including aspects of happiness and satisfaction with life as a whole” [3]. Health-related Quality of life (HRQOL) is a multidimensional aspect thatdefines how disease and treatment affect a patient’s
sense of overall function and well-being [4]. Also, theclinical symptoms of cancer and the aggressive treatment substantially impact a patient’s life in multiple
aspects, which may affect HRQOL. As a result, children
and families have experienced a reduction in their QOL
after being diagnosed with cancer and treatment has
been initiated [5]. In Pakistan, cancer patients exhibiteda lower HRQOL than healthy youngsters [6]. For thesereasons, the intention of cancer treatment currently is
to cure the disease and improve the QOL of patientsand families.
To achieve this goal, an assessment and understanding of HRQOL among children with cancer both fromthe patient themselves and their family’s perspectives
is crucial. Our study aims to illustrate HRQOL among
Thai children with cancer using a standard instrumental questionnaire, The Pediatric Quality of Life
Inventory (PedsQL) 3.0 Cancer Module, Thai Version[7], and explore factors associated with HRQOL. The
results would establish adapted treatment strategies toachieve patient outcomes of both physical and mental health for Thai children with cancer, which may befurther expanded to neighbors having a similar context
perspective.

Page 2 of 10

Methods
Participants

Oncology patients aged 2 to 18 years and their parents or
guardians, who were treated primarily at the Division of
Hematology-Oncology, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand from May 1,
2018, to November 30, 2019, were eligible for this study.
Patients with terminal illnesses, developmental disorders,intellectual disabilities, learning disorders, in palliative
care or illiterate were excluded from the study. All participants and their legal guardians were provided informed
consent and assented to participate in the study.
Instrument

The original version of the PedsQL 3.0 Cancer Module
was translated to Thai under a full linguistic validation
process. The PedsQL 3.0 Cancer Module, Thai version
was approved by the Mapi Research Trust for academic
purposes, with evidence of excellent internal consistency
among child and parent reports (0.92 and 0.94, respectively) [7].
The PedsQL 3.0 Cancer Module, Thai version was
designed to evaluate the QOL among children and young
adults with cancer aged 2 to 25 years. The PedsQL 3.0
Cancer Module has two parallel versions (child and parent forms) in each different age group: child (5–7, 8–12,
13–18 and 18–25 years) and parent (2–4, 5–7, 8–12,
13–18 and 18–25 years) reports. The PedsQL 3.0 Cancer Module consists of 8 domains and a total of 27 items:
1) pain and hurt (2 items), 2) nausea (5 items), 3) procedural anxiety (3 items), 4) treatment anxiety (3 items), 5)
worry (3 items), 6) cognitive problems (5 items), 7) perceived physical appearance (3 items) and 8) communication (3 items). The child and parent rate a score in each
item based on a 5-point Likert scale (0 = never, 1 = almost
never, 2 = sometimes, 3 = often, and 4 = almost always).
The 5- to 7-year child report is exceptional; the childrates a score in each item based on a 3-point Likert scaleaccording to a visual aid, (0 = never/happy face, 2 = sometimes/neutral face, and 4 = almost always/sad face). The
score in each item was reverse-scored and linearly transformed to a 0 to 100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25,
4 = 0). Scores in each domain were calculated as the sumof the items divided by the number of items answered.
Higher scores indicated a better HRQOL.
Procedures

After informed consent and assent forms were obtained,
parents then completed the demographic data information and PedsQL 3.0 Cancer Module, Thai Version. For
patients aged 2 to 4 years, only parents filled out thequestionnaires. Children aged ≥ 5 years completed theSudnawa et al. BMC Pediatrics(2024) 24:531

PedsQL 3.0 Cancer Module, Thai Version separately fromtheir parents. Children aged 5 to 7 years completed thequestionnaires with support from a research assistant toensure reading competency and to clarify each question.
Children aged 8 to 18 completed the questionnaires independently or with support when needed.
This study comprised a secondary analysis of data fromthe related cohort of Sudnawa KK, et al. [7] and wasapproved by the Institutional Review Board, Royal Thai
Army Medical Department according to the ethics principles of the Declaration of Helsinki (1964) and its revision (reference number: IRBRTA 700/2561). The study
was also registered and approved by the Thai Clinical Trials Registry (TCTR https://​www.​thaic​linic​altri​als.​org/),
number TCTR20200904001 (04/09/2020).
Statistical analysis

Demographic data were analyzed using descriptive statistics and presented as mean with standard deviation (SD)for continuous variables and demonstrated as frequency
and percentage for categorical variables. A paired-sample
t-test was conducted to evaluate the differences between
the HRQOL scores of the child and parent reports fromeach domain of the PedsQL 3.0 Cancer Module. Univariate and multivariate linear regression were used to evaluate factors correlated to HRQOL and which particulardomains of the PedsQL3.0 Cancer Module were influenced. Statistical significance was considered at p < 0.05.
Statistical analysis was performed using IBM SPSS Software for Windows, Version 23.0 (Armonk, NY: IBM
Corp., USA).

Results
Patient characteristics

Eighty-five eligible children with cancer and their parents participated in the study. Patient demographic data
including age, sex, diagnosis, disease and treatment status, hospital visits, school attendance, parental marriage
status and household incomes are summarized in Table 1.
The male to female ratio was 3:2, and the mean age ofpatients was 10.8 ± 5.5 years. The mean duration of disease from diagnosis to assessment was 4.99 ± 4.96 years.
The most common cancer types were acute lymphoblastic leukemia (ALL), brain or central nervous system (CNS) tumors, osteosarcoma, neuroblastoma andchronic myeloid leukemia, in rank. Four (4.7%) patientswere in advanced stage. Most participants were newly
diagnosed (70.6%), in remission (22.4%), and in relapse/
refractory (7%) of disease, in rank. Therefore, 77.6% of
patients were in the treatment process while 22.4% of
patients had completed treatment. The majority of treatments received were chemotherapy (62.4%) and surgery(15.3%). Treatment complications occurred for 81.2%,

Page 3 of 10

Table 1 Patient demographic data (n = 85)
Demographic data (n = 85)n(%)

Age (years)
Mean ± SD

10.82 ± 5.48

GenderaMale50(58.8)

Female35(41.2)

Duration of disease (years)
Mean ± SD

4.99 ± 4.96

Diagnosis
Hematologic malignancy

48(56.5)   Acute lymphoblastic leukemia

32(66.7)   Chronic myeloid leukemia

5(10.4)  Non-Hodgkin lymphoma4(8.3)   Acute myeloid leukemia

3(6.3)  Hodgkin lymphoma1(2.1)  Others3(6.3)

Solid tumors

37(43.5)   Brain/central nervous system tumor

13(15.3)  Osteosarcoma

10(27)  Neuroblastoma

9(24.3)   Wilms tumor

1(2.7)  Hepatoblastoma

1(2.7)  Rhabdomyosarcoma

1(2.7)  Ewing sarcoma

1(2.7)  Retinoblastoma

1(2.7)

Stage of disease
Advanced (stage III, IV for lymphomas and solid tumors)4(4.7)

Disease status
Newly diagnosed60(70.6)

Relapse/refractory6(7)Remission of disease19(22.4)

Number of outpatient visits/month
Mean ± SD

1.3 ± 1.3

Number of hospitalizations/month
Mean ± SD

1.0 ± 1.3

Treatment status
During treatment

66(77.6)

Completed treatment

19(22.4)

Type of treatment
Chemotherapy

53(62.4)

Surgery13(15.3)

Radiation8(9.4)

Hematopoietic stem cell transplantation

1(1.2)

Complications

69(81.2)

Electrolyte imbalance59(69.4)

Febrile neutropenia

37(43.5)

Mucositis

10(11.8)

Current school attendance

54(63.5)

Primary school or lower

31(57.4)

Secondary school or higher

23(42.6)

Sudnawa et al. BMC Pediatrics(2024) 24:531

Page 4 of 10

Table 1 (continued)
Demographic data (n = 85)n(%)

Parental status
Married69(81.2)

Divorced/separated

16(18.8)

Household incomes (THB/month)< 15,000

33(38.8)

15,000—30,00020(23.5)> 30,000

32(37.6)

Data are presented as mean ± SD for continuous variables and number (%) for
categorical variables
Abbreviations: SD standard deviation, THB Thai bahtaDuration of disease refers to the time from diagnosis to assessment datewith mostly encountered with electrolyte imbalance(69.4%), followed by febrile neutropenia (43.5%). The
number of monthly outpatient visits and hospitalizations
totaled 1.3 ± 1.3 and 1.0 ± 1.3, respectively.
Fifty-four (63.5%) patients attended school, of which
57.4% studied in primary school or lower and 42.6% studied in or higher than secondary school level. Most parents were married (81.2%) and still lived together withhousehold monthly incomes of less than 15,000 THB(38.8%) (Table 1).
HRQOL among children and parents

Overall, children with cancer reported higher HRQOL
scores of the PedsQL 3.0 Cancer Module compared withthose found in parent reports, except for the perceived
physical appearance and communication domains. The
highest HRQOL scores of the PedsQL 3.0 Cancer Module in child reports were observed in the treatment anxiety domain (88.15 ± 17.37), while the nausea domain(78.98 ± 18.99) had the highest HRQOL scores in parent reports. On the contrary, the lowest HRQOL scoresin child reports were observed in the cognitive problems domain (66.31 ± 22.26), while the worry domain(55.34 ± 30.37) had the lowest HRQOL scores in parent
reports.
However, statistically significant differences were noted
between child and parent reports on procedural anxiety (70.05 ± 26.67 vs. 60.03 ± 25.6, p = 0.003), treatment
anxiety (88.15 ± 17.37 vs. 76.82 ± 26.7, p = 0.001), worry(66.67 ± 25.59 vs. 55.34 ± 30.37, p = 0.003) and total score(74.37 ± 15.7 vs. 70.42 ± 17.15, p = 0.034) (Supplementary
Table 1).
Factors associated with overall HRQOL among children
and parents

From the parent report, patients having completed thetreatment were positively correlated to the total HRQOL

score (β = 9.34, p = 0.039). On the contrary, the number ofmonthly hospitalizations (β = -4.49, p = 0.002) and number of monthly outpatient visits (β = -3.53, p = 0.019) were
negatively correlated to the total HRQOL score (Table 2).
Other factors including age, sex, duration of disease,cancer type, treatment, febrile neutropenia occurrence,school or family factors were unassociated with the
HRQOL.
Using multivariate analysis, only the number ofmonthly hospitalizations remained independently, negatively correlated to the total HRQOL score from the parent reports (β = -5.77, p = 0.044) (Table 3).
Factors associated with individual domains of HRQOL
among parents

Each domain of the PedsQL 3.0 Cancer Module parent
report was analyzed to determine whether the number ofmonthly hospitalizations, outpatient visits or treatment
with chemotherapy correlated to HRQOL. The number of outpatient visits and/or hospital admissions was
influenced by pain and hurt, nausea, procedural anxiety
and communication domains (p < 0.05). Treatment withchemotherapy was influenced by pain and hurt and procedural anxiety (p < 0.05). Only the number of monthly
hospitalizations remained independent and significantly
correlated to the procedure anxiety domain (β = -13.2,
p = 0.005) (Fig. 1 and Supplementary Table 2).

Discussion
HRQOL assessed by PedsQL3.0 Cancer Module, Thai
version from parent and child reports received mean
total scores of 70.4 and 74.4, respectively, which wascomparable with other countries either in resource-available or limited-resource settings [8–15]. However, thetotal HRQOL scores in this study were higher than thoseof related studies [6, 16], which had fewer participants
comparing between healthy children and children withcancer [6] or in hospitalized patients [16]. On the other
hand, our study had slightly lower scores than those of
the study of Ocak E, et al., [17] enrolling only children
with leukemia in a younger age range (Table 4).
A strong agreement between child and parent
reports was found in observable functioning or physical HRQOL domains [7]. Nevertheless, a disagreement
was detected in nonobservable functioning or emotional or social HRQOL domains. In general, patientsthemselves reported higher HRQOL scores of the PedsQL 3.0 Cancer Module compared with parents, except
for the perceived physical appearance and communication domains. These discordances were similarly
illustrated in related studies by Sand P, et al. [9] andTomlinson, D et al. [18]. The treatment consequences
definitely change physical appearance such as hair loss,

Sudnawa et al. BMC Pediatrics(2024) 24:531

Page 5 of 10

Table 2 Univariate analysis of factors correlated with HRQOL scores of PedsQL 3.0 Cancer Modulebetween children and parents
Factors

Parent report(n=85)βChild report(n=65)
p-value95%CI

βp-value

95%CI

Sex; male

-0.99

0.789

-8.68 to 6.70

-1.44

0.731

-9.76 to 6.88

Age (years)

0.32

0.354

-0.37 to 1.02

0.03

0.946

-0.96 to 1.02

aDuration of disease (years)

0.56

0.143

-0.20 to 1.32

-0.19

0.628

-0.96 to 0.58

Number of outpatient visits/month

-3.53

0.019

-6.45 to -0.60

-1.81

0.209

-4.66 to 1.04

Number of hospitalization/month

-4.49

0.002

-7.32 to -1.67

-0.97

0.514

-3.92 to 1.98

9.34

0.603

-9.63 to 5.62

-3.48

0.388

-11.49 to 4.52

Diagnosis
Hematologic malignancy
Solid tumors
Disease status
During treatment
Completed treatment
Treatment with chemotherapy

9.34

0.039

0.49 to 18.20

1.11

0.798

-7.53 to 9.77

-6.62

0.090

-14.30 to 1.06

0.16

0.968

-7.81 to 8.13

Treatment with surgery

2.30

0.664

-8.20 to 12.81

5.51

0.293

-4.88 to 15.90

Encountered with febrile neutropenia
during treatment

-0.61

0.873

-8.25 to 7.02

-2.17

0.589

-10.16 to 5.82

Current school attendance

4.63

0.241

-3.17 to 12.43

3.20

0.495

-6.11 to 12.50

-7.27

0.119

-16.48 to 1.95

-0.38

0.937

-10.05 to 9.29

0.86

0.861

-8.82 to 10.54

5.73

0.230

-3.73 to 15.19

1.68

0.440

-2.63 to 6.0

1.38

0.543

-3.13 to 5.89

School level
Primary school or lower
Secondary school or higher
Parental status
MarriedDivorces/separated
Household income (THB/month)<15,000
15,000-30,000>30,000aDuration of disease refers to the time from diagnosis to assessment date

Univariate analysis of factors associated with HRQOL scores of PedsQL 3.0 Cancer Module between child- and parent reports were calculated using linear regression. P<0.05 is considered as statistical significanceAbbreviations:HRQOL Health-related quality of life, PedsQL The Pediatric Quality of Life Inventory, THB Thai baht

Table 3 Multivariate analysis of factors associated with total HRQOL scores of PedsQL 3.0 Cancer Module between children andparents
Factors

Parent report (n = 85)βp-valueChild report (n = 65)
95%CI

β

p-value

95%CI

Number of outpatient visits/month

0.82

0.773

-4.84 to 6.49

-4.79

0.121

-10.87 to 1.30

Number of hospitalization/month

-5.77

0.044

-11.4 to -0.17

1.41

0.663

-5.05 to 7.88

Treatment with chemotherapy

-2.33

0.583

-10.76 to 6.10

1.41

0.761

-7.84 to 10.67

Treatment with surgery

3.28

0.527

-6.99 to 13.54

5.55

0.304

-5.16 to 16.26

Multivariate analysis of factors associated with HRQOL scores of PedsQL 3.0 Cancer Module between child- and parent reports were calculated using linear regression.
P < 0.05 is considered as statistical significanceAbbreviations: HRQOL Health-related quality of life, PedsQL The Pediatric Quality of Life Inventory

surgical scars or extremity loss which negative effectto patient emotions [19]. Physical appearance perception comprises internalized and emotional sensations

that may be either difficult to interpret or consideredless sentimental by the parents. Marginean CO et al.
[20] reported that children were not satisfied with theSudnawa et al. BMC Pediatrics(2024) 24:531

Page 6 of 10

Fig. 1 Forest plot shows multivariate analysis factors correlated with HRQOL scores of PedsQL 3.0 Cancer Module parent reports in pain and hurt,
nausea, procedural anxiety, and communication domains

amount of time their doctor communicated with them.
These underline the communication between physicians and pediatric patients remains insufficient or
inappropriate, especially in serious situations whichchildren may be left behind. Good communication andemotional supports between children, their care givers
and doctors may better comprehend the patients’ emotions and support for each other.
From the parents’ perspectives, higher score domains
were reported for “Nausea” and “Pain and hurt.” This may
imply that symptomatic and supportive care programs in
Thailand was sufficient to provide positive emotions forparents, especially the appropriate protocol for bedsideinvasive procedural sedation among patients undergoing
multiple painful procedures such as bone marrow procedures or lumbar puncture [21, 22]. Moreover, providing
proper analgesics and anti-emetics can improve HRQOL[23–25], particularly in patients who require repeated or
multiple invasive procedures for diagnosis and treatment[21, 22], ranging from weekly intrathecal chemotherapy
during the induction phase to every three months during
the maintenance phase of ALL treatment [26]. A higher
HRQOL score in the communication domain was demonstrated in parent reports rather than child reports corresponding to many studies [8, 11, 17]. It conveys that thecommunication between families and medical teams particularly shared decision-making will benefit and improve
HRQOL among children with cancer [27].

Some aspects were contradictory between parent
and child perspectives, for example, “Treatment anxiety” received superior HRQOL scores in child reports
compared with those in parent reports, which was similar to related studies [9, 10, 13, 14, 17]. The lower scoredomains from the parent reports included “Worry” and“Procedural anxiety” whereas “Worry” and “Cognitive
problems” were addressed as the lowest score domain
in child reports which was parallel to related studies [8,10, 12, 14, 16, 17]. Anxiety and depression-related findings were frequently reported among children with cancer [28, 29]. Screening tests for early detection of moodproblems and early intervention such as enhancing communication skills or psychotherapy will support patientsand families with cancer [30].
Cognitive problems among children with cancer may
be directly caused by specific types of cancer and treatment, such as CNS tumors, cranial irradiation, chemotherapy crossing blood–brain barriers or prolonged
hospitalization leading children to incompetency inschool activities [31, 32]. Early detection of cognitive
problems among pediatric oncology patients along withbroad strategies such as educational intervention, andcognitive training are essential to remediate cognitiveand learning dysfunction [31, 33].
Interestingly, we found that the total HRQOL score
was positively correlated to completed treatment status. This finding corresponded to that of Meeske K

73.3

70.4

Communication

Total score

74.4

71.6

73.8

66.3

70.1

79.8

72.3

80.2

67.4

78.3

71.2

67.6

60.1

78.3

94

332
52.4

13

69.3

77.6

67.6

70.2

69.2

80.3

69.7

59.7

70.3

77

82.4

73.2

75.3

75.6

89.5

78.2

72

77.9

75.1

78.6

77.7

72.3

55.6

89.6

76.9

74.1

81

Parent Child Child

41.5

9.9

72.8

86.6

75.7

80.5

68.6

67.7

77.2

55.2

70.4

Parent

48.2

12.5

85
55.1

10.5

245

Tsuji N [13]

55

6.6

98

Sitaresmi MN
[14]

62.7

10.5

51

Hegazy A
[15]

NA

71.6

77.9

73.9

62.9

67.1

64.1

73.2

77.4

NA

72.2

76.4

71.7

68.1

71.7

68

75.7

74.2

74.9

62.2

73.8

68.8

81.4

84.9

63.2

80.5

82.9

77.9

67.0

70.3

72.4

76.6

93.1

72.9

83

84.7

72.2

60.2

82.5

77.6

74.6

74.4

60.1

78.8

71

77.1

68.3

76.4

76.9

75.5

88.2

69.9

82.6

80.1

73.5

82.7

69.8

92.5

61.8

66.0

60.8

76.9

65.6

Parent Child Parent Child Parent Child Child

57.9

8.8

266

Santos S [10] Abu-Saad Ji Y [12]Huijer, H[11].

Abbreviation: HRQOL Health-related quality of life, NA Not available, PedsQL The Pediatric Quality of Life Inventory

76.2

Perceived physicalappearance

66.7

55.3

64.3

Worry

60.0

76.8

Procedural anxiety

Treatment anxiety

Cognitive problems

88.2

79.0

75.5

Nausea79.3

77.0

Pain and hurt

46.3

58.8

Parent Child Parent

Male (%)

Report

7

95

85

10.8

N

Age (years)

Alabbas F [8] Sand P [9]This study

Table 4 Assessment of HRQOL scores of PedsQL 3.0 Cancer Module in literature review

59.1

65.0

70.1

62.5

45.6

61.4

56.8

54.6

67.3

Child

65.8

12.1

38

Nunns M
[16]

79.6

84.6

72.8

81.5

85.1

83.2

67.4

80.5

81.9

82.0

82.6

78.7

78.1

81.5

90.9

81.7

84.1

78.7

Parent Child

52.5

7.3

59

Ocak E [17]Sudnawa et al. BMC Pediatrics(2024) 24:531
Page 7 of 10

Sudnawa et al. BMC Pediatrics(2024) 24:531

et al., [34] which found that patients with CNS tumors
and ALL who were undergoing treatment had lower
HRQOL scores of PedsQL™ 3.0 cancer module compared to those who had completed treatment. This
result can be attributed to the absence of hospitalization, treatment-related anxiety, and unpleasant emotions. Furthermore, we addressed that the number ofmonthly in- and outpatient visits were negative indicators correlating to the HRQOL score. Hospitalizations
subsequently remained independent and negatively
correlated to the "Procedure anxiety" domain from theparent report. However, Baggott CR et al. [35] identified that pediatric oncology patients with prolonged
hospitalization possibly had a higher nausea scoreassessed by PedsQL™ 3.0 cancer module, but no correlation was observed in the total or “Procedure anxiety” HRQOL score. These contradicting results may
stem from different intravenous catheterization accesslevels between resource-available and resource-limited settings. In resource-available countries, central
venous catheters (CVC) always applied to all children
with cancer needing repeated systemic chemotherapy,
in contrast with low and middle income countries inwhich patients regularly received services for repeated
peripheral venous catheters at each single visit [21].
This made patients more anxious when hospitalization was required. CVC placement should be considered among patients requiring multiple invasive anddistressing procedures or prolonged treatment, especially for inhouse patients. Moreover, early detectionof infectious complications which is the most common
cause of prolonged and increased number of hospitalizations, may increase HRQOL among children withcancer.
Nonpharmacologic treatments, either hypnosis or
nonhypnosis interventions, may reduce proceduralanxiety for pediatric inpatients [36], particularly thoseyounger than five years who reported a strong association with “Procedural anxiety” [8, 14, 37, 38]. Robson
PC, et al. [37] reported lower household income correlated to poorer child’s HRQOL in the US, which was
not identified in our study. This observation may be
explained by the accessible and successful implementation of Thailand’s universal health coverage applying to
all Thais regardless of different income levels [39].
This is the very first study to initiate the assessmentof the HRQOL among Thai children with cancer using
the standard tool of PedsQL 3.0 Cancer Module in theThai Version, applied in both parent and child reports.
Results will elucidate HRQOL in children with cancer
and further generate an appropriate institutional policythat may expand to the whole nation to improve the
QOL for Thai children with cancer.

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Limitations of the study

The relatively small sample size in some age groups witha single institution may have affected the generalizationand power to identify outcomes. However, the study’s
focus on the Thai population may be of interest to the
Asian-Pacific community. Additional factors such as
delayed diagnosis, should be further explored to determine their impact on HRQOL. Longitudinal HRQOL
follow-up studies in multicenter settings or focus-groupstudies are recommended to gain a deeper understanding
and better comprehension of HRQOL among Thai children with cancer.

Conclusion
HRQOL among Thai children with cancer was desirablefrom both children and parents’ perspectives, comparable with most countries around the world. Differences
between child and parent HRQOL scores were observed.
Cognitive issues and unpleasant emotions, especiallyworries, impact HRQOL. The frequency of outpatient
visits and hospitalizations diminished HRQOL and wasfurther associated with procedure anxiety.
This study emphasizes the importance of assessing the
HRQOL and raises concerns regarding patient and family support services, appropriate protocols for chemotherapy-induced nausea and vomiting, bedside invasive
procedural sedation to reduce nausea and vomiting, as
well as worrisome and treatment-related anxiety. Early
screening and early intervention can reduce hospitalizations. Good communication with early psychologicalconsults along with in-house educational approaches thatwill enhance the patient’s cognitive function should beapplied among children with cancer.
AbbreviationsALL	Acute lymphoblastic leukemia
CNS	Central nervous system
CVC	Central venous catheter
HRQOL	Health-related quality of life
PedsQL	The Pediatric Quality of Life Inventory
QOL	Quality of life
SD	Standard deviation
TCTR​	Thai Clinical Trials Registry
THB	Thai bahtWHO	World Health Organization

Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12887-​024-​05010-8.
Supplementary Material 1
Supplementary Material 2
Acknowledgements
The authors gratefully acknowledged the Mapi Research Trust for providing
translational agreement approval and permission to use the Thai Versionof the PedsQL 3.0 Cancer Module for academic purposes and Mrs. SupakSudnawa et al. BMC Pediatrics(2024) 24:531

Cae-Ngow, Office of Research and Development, Phramongkutklao Hospital,
and Phramongkutklao College of Medicine for statistical analysis. The authors
also thank the physicians, nurses, patients and families for participating in thisstudy.
Authors’ contributions
KS contributed to conceptualizing and designing the study, interpreted data
and drafted and edited the manuscript. JY was involved in patient care andcollected and interpreted the data. CM contributed to patient care, conceptualized and designed the study, managed the program overall, analyzed, andinterpreted data, and was a major contributor in writing the manuscript. All
authors contributed to patient care, collected data, and critically reviewed andapproved the final version of the manuscript.
Funding
The funding to conduct and analyze the study was provided by the Phramongkutklao College of Medicine.
Availability of data and materials
The datasets generated or analyzed during the current study are not publicly
available due to privacy or ethics restrictions. The data are available from thecorresponding author upon reasonable request.

Page 9 of 10

6.
7.

8.
9.
10.
11.
12.

Declarations
Ethics approval and consent to participate
Written informed consent and assent forms were obtained from all participants. This study was approved by the Institutional Review Board, Royal Thai
Army Medical Department (reference number: IRBRTA 700/2561) following the
ethics principles of the Declaration of Helsinki (1964) including revisions.
The study was also registered and approved by the Thai Clinical Trials Registry (TCTR https://​www.​thaic​linic​altri​als.​org/), number TCTR20200904001(04/09/2020).

13.

Consent for publication
Not applicable.

16.

Competing interests
The authors declare no competing interests.

17.

Author details
1
Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine,
Bangkok, Thailand. 2 Phayao Hospital, Ministry of Public Health, Phayao,
Thailand. 3 Division of Hematology/Oncology, Department of Pediatrics,
Phramongkutklao Hospital and Phramongkutklao College of Medicine, 315
Ratchawithi Rd. Ratchathewi, Bangkok 10400, Thailand.

18.

Received: 15 February 2024 Accepted: 13 August 2024

14.
15.

19.
20.
21.

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