Health and Quality of Life Outcomes This Provisional PDF corresponds to the article as it appeared upon acceptance Fully formatted PDF and full text (HTML) versions will be made available soon Measuring health-related quality of life in children with cancer living in mainland China: feasibility, reliability and validity of the Chinese mandarin version of PedsQL 4.0 Generic Core Scales and 3.0 Cancer Module Health and Quality of Life Outcomes 2011, 9:103 doi:10.1186/1477-7525-9-103 Yi Ji (jijiyuanyuan@163.com) Siyuan Chen (siy_chen@163.com) Kai Li (likai2727@163.com) Nong Xiao (xiaonongwl@163.com) Xue Yang (jijiyuanyuan520@163.com) Shan Zheng (szheng@shmu.edu.cn) Xianmin Xiao (xmxiao@shmu.edu.cn) ISSN Article type 1477-7525 Research Submission date 30 August 2011 Acceptance date 23 November 2011 Publication date 23 November 2011 Article URL http://www.hqlo.com/content/9/1/103 This peer-reviewed article was published immediately upon acceptance It can be downloaded, printed and distributed freely for any purposes (see copyright notice below) Articles in HQLO are listed in PubMed and archived at PubMed Central For information about publishing your research in HQLO or any BioMed Central journal, go to http://www.hqlo.com/authors/instructions/ For information about other BioMed Central publications go to http://www.biomedcentral.com/ © 2011 Ji et al ; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited Measuring health-related quality of life in children with cancer living in mainland China: feasibility, reliability and validity of the Chinese mandarin version of PedsQL 4.0 Generic Core Scales and 3.0 Cancer Module Yi Ji1, Siyuan Chen2, Kai Li1, Nong Xiao3, Xue Yang3, Shan Zheng1, Xianmin Xiao1* Department of Pediatric Surgery, Children’s Hospital of Fudan University, Shanghai, 201102, China Department of Pediatric Healthcare, Children’s Hospital of Fudan University, Shanghai, 201102, China Department of rehabilitation center, Children’s Hospital of Chongqing Medical University, Chongqing, 400014, China Email addresses: YJ: jijiyuanyuan@163.com; SYC: siy_chen@163.com; KL: likai2727@163.com; NX: xiaonongwl@163.com; XY: jijiyuanyuan520@163.com; SZ: szheng@shmu.edu.cn; XMX: xmxiao@shmu.edu.cn *Correspondent author: Xianmin Xiao, M.D., PhD Department of Pediatric Surgery, Children’s Hospital of Fudan University 399 Wanyuan Road, 201102, Shanghai, China Tel.: +86 21 64931212; Fax: +86 21 64931211; Email address: xmxiao@shmu.edu.cn Abstract Background: The Pediatric Quality of Life Inventory (PedsQL) is widely used instrument to measure pediatric health-related quality of life (HRQOL) for children aged to 18 years The purpose of the current study was to investigate the feasibility, reliability and validity of the Chinese mandarin version of the PedsQL 4.0 Generic Core Scales and 3.0 Cancer Module in a group of Chinese children with cancer Methods: The PedsQL 4.0 Genetic Core Scales and the PedsQL 3.0 Cancer Module were administered to children with cancer (aged 5-18 years) and parents of such children (aged 2-18 years) For comparison, a survey on a demographically group-matched sample of the general population with children (aged 5-18) and parents of children (aged 2-18 years) was conducted with the PedsQL 4.0 Genetic Core Scales Result: The minimal mean percentage of missing item responses (except the School Functioning scale) supported the feasibility of the PedsQL 4.0 Generic Core Scales and 3.0 Cancer Module for Chinese children with cancer Most of the scales showed satisfactory reliability with Cronbach’s α of exceeding 0.70, and all scales demonstrated sufficient test-retest reliability Assessing the clinical validity of the questionnaires, statistically significant difference was found between healthy children and children with cancer, and between children on-treatment versus off-treatment ≥12 months Positive significant correlations were observed between the scores of the PedsQL 4.0 Generic Core Scale and the PedsQL 3.0 Cancer Module Exploratory factor analysis demonstrated sufficient factorial validity Moderate to good agreement was found between child self- and parent proxy-reports Conclusion: The findings support the feasibility, reliability and validity of the Chinese Mandarin version of PedsQL 4.0 Generic Core Scales and 3.0 Cancer Module in children with cancer living in mainland China Background Currently, an increasing number of children with cancer are cured for their diseases in the world, including China However, common treatments such as surgery, radiotherapy, chemotherapy, whether palliative or curative, can have deleterious side-effects affecting many aspect of the quality of children’s lives — not only physical aspects but also social and emotional aspects [1, 2] Survivors may experience a number of long-term adverse effects from the tumor and its treatment [3-6] Focusing on the patients’ psychosocial and social well-being in addition to their physical health is an essential requirement in accordance with the WHO definition of health and well-being [7] Health-related quality of life (HRQOL) is a continuous concept influenced by a person’s objective assessments of function or health status as well as subjective perceptions of their personal health [8] It is increasingly acknowledged as an important health outcome measure in clinical trials and health services research and evaluation However, one challenge in measuring HRQOL in children is that the instrument must account for the continuous physical, emotional, social and cognitive development during childhood and adolescence Another problem is the questionnaires should provide the required information [9] Although there are a number of generic HRQOL instruments applicable to children, assessment has relied exclusively on proxy-report [10], or the concordance between self- and proxy-report has been demonstrated to be imperfect [11] Given the multidimensional impact cancer has on children, it is necessary to find an appropriate instrument to capture and evaluate the HRQOL of these children The Pediatric Quality of Life Inventory (PedsQL) is one of the more promising HRQOL measures for children aged 2-18 years [12, 13] The advantages of PedsQL included brevity, availability of age-appropriate version, and parallel for child and parent The approach is modular, with Generic Core Scales complemented by disease-specific modules, such as the PedsQL Cancer Module [14-19] The PedsQL 4.0 Generic Core Scales was specifically designed for application in both healthy and patient populations The PedsQL 3.0 Cancer Module was designed to measure HRQOL dimensions specific to pediatric cancers Studies with PedsQL indicate that both healthy children and children with cancer aged 5-18 years can self-report their HRQOL [20-22] As the population of Chinese children nears 300 million, a conservative projection of 45 thousands new cases of pediatric cancer each year can be made [23] However, limited information is available to understand the HRQOL of children with cancer living in mainland China The objective of this study was to investigate the feasibility, reliability, and validity of the Chinese mandarin version of the PedsQL 4.0 Generic Core Scales and 3.0 Cancer Module in children with cancer Method Participants and Settings This study was developed in the cities of Shanghai and Chongqing, China We recruited children with cancer and their parents by means of convenience samples from children’s hospitals at the cities Children aged to 18 years who were diagnosed with cancer were included in this study, and the parents were included if their child was to 18 years old Children were excluded from this study if they had comorbid disease or major developmental disorders The sample size needed to procedure medium correlation (0.30) in the examination of discriminant validity was calculated 154 subjects were needed to take part in the study when we set the type Ⅰerror at 1% and the statistical power at 90% We estimated that approximately more than 60-70% of participants would agree to participate Finally, two hundred and seventy five families were approached for the study Controls were 300 families of healthy children aged to 18 years recruited from schools, with distributional matching to the patients on age and gender Measurement PedsQL 4.0 Generic Core Scales The 23-item PedsQL 4.0 Generic Core Scales encompasses the essential core domains for pediatric HRQOL measurement: (1) physical functioning (8 items), (2) emotional functioning (5 items), (3) social functioning (5 items), and (4) school functioning (5 items) It comprises of parallel child self-report and parent proxy-report format Child self-report includes ages 5-7 (young children), 8-12 (children), and 13-18 (teens) years Patent proxy-report includes ages 2-4 (toddlers), 5-7, 8-12, and 13-18 years The items for each of the forms are essentially identical, differing in developmentally appropriate language, or first or third person tense The instructions ask how much of a problem each item has been during the past one month A 5-point response scale is utilized across child self-report for ages 8-18 and parent proxy-report (0 = never a problem; = almost never a problem; = sometimes a problem; = often a problem; = almost always a problem) The child-report for children aged 5-7 is completed with the help of an interviewer To increase its ease of use, the rating scale has been reworded and simplified to a 3-point scale (0 = not at all a problem; = sometimes a problem; = a lot of a problem), with each response choice anchored to a happy to sad faces scale Items are reverse-scored and linearly transformed to a 0-100 scale, with higher scores indicating a better HRQOL Scale scores are computed as the sum of the items divided by the number of items answered If more than 50% of the items in the scale are missing, the scale score is not computed To create the Psychosocial Functioning score, the mean is computed as the sum of the items divided by the number of the items answered in the Emotional, Social, and School Functioning Scale PedsQL 3.0 Cancer Module The PedsQL 3.0 Cancer Module instrument encompasses subscales: (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 cognitive problems scales were modified to include fewer items for children aged 2-7 years The format, instructions, Likert response scale, and scoring method of the Cancer Module are identical to the PedsQL 4.0 Generic Core Scales [24] Procedure The investigation was performed by research students majoring in Pediatrics and nurses All of them were trained in interviewing and administering questionnaires On-treatment status was defined as patients who were receiving medical treatment to induce remission Off-treatment status was defined as patients who completed all therapy by the time of the assessment [25, 26] The on-treatment patient was interviewed while hospitalized The off-treatment patient was interviewed during clinic visits Parents were interviewed first, and were asked whether they would allow their children to participate in the study The parents and their children completed the questionnaire independently during the pediatric patients’ hospitalization or outpatient department visit All the parents were asked to fill out the PedsQL 4.0 Generic Core Scales and the Cancer Module The children were required to complete the questionnaires by self-administration except the Young Children by interview-administration [19] The interviewers were available to assist the completion of the questionnaires if the parents/children had questions on semantic or conceptual understanding They were also responsible for collecting and checking the questionnaires to ensure that there were no missing data or logical mistakes Test-retest reliability was assessed at Children’s Hospital of Fudan University (the same hospital in Shanghai) Thirty-four families with patients in stable condition according to their physician completed the PedsQL measures a second time (with an interval of 1-3 weeks between applications) For control group, the questionnaires interviews were conducted at schools Written information was sent to parents who completed questionnaires at home, returning them to school by a specified date Cross-culture adaptation and Ethical considerations The Chinese Mandarin Version was provided by MAPI Research Trust that translated the version according to their standardized procedures Briefly, the instruments were translated independently into Chinese by two professional translators (native Chinese speakers) and translated back into English by two English native speakers (bilingual in Chinese) Then, a comparison between the backward version and the original version was assessed in order to detect any misunderstandings or mistranslations in the intermediary forward version of the questionnaires [27, 28] 15 children with cancer participated in pilot testing along with their parents In consideration of the Chinese sociocultural environment, we avoided using the term ‘cancer’ or ‘tumor’ in questionnaires The permission was obtained from its developer, James W Varni, PhD The human subject institutional review boards at each hospital approved the study All subjects were given detailed written information about the methods, aims, and the voluntary nature of participation in the study, and written parental informed consent and child assent were obtained prior to enrollment Statistical analysis Feasibility was determined from the average completion time and percentage of missing response The average completion time was defined as the mean of completion time of the Generic Core Scales and Cancer Module The percentage of all possible item-responses left unanswered was calculated for each subject on each single and summary scale and averaged over subjects [29] The presence of floor and ceiling effects was assessed for the subscales scores and summary scores Scale internal consistency reliability was determined by calculating Cronbach’s coefficient alpha Scales with reliabilities of 0.70 or greater are recommended for comparing patients groups, while a reliability criterion of 0.90 is recommended for analyzing individual patient scale scores [30] To determine retest reliability, the intra-class correlation coefficients (ICCs) between the initial test and retest scores was examined, with an ICC value of 0.40 representing moderate, 0.60 good, and 0.80 high agreement [31] Discriminant validity was determined using the known-groups method The Generic Core Scales scores were compared between groups differing in known health conditions (healthy children and children with cancer) HRQOL scores of children from the general population and children with cancer were compared using independent sample t test To determine the magnitude of the differences, effect sizes were evaluated Effect size as utilized in these analyses was calculated by taking the difference between the healthy sample mean and the oncology sample mean, divided by the pooled standard deviation [32] Additionally, analyses of variance also were conducted to examine whether there were differences in Generic Core Scales and Cancer Module scores among children with cancer on treatment and off-treatment (≤ 12 months or > 12 months) 202 n 202 202 165 Psychosocial functioning Emotional functioning Social functioning School functioning 266 202 Physical functioning 266 266 266 195 Physical functioning Psychosocial functioning Emotional functioning Social functioning School functioning 60.55 (23.6) 73.49 (17.6) 64.07 (19.5) 65.06 (18.7) 66.13 (20.5) 65.54 (18.8) 62.19 (22.5) 78.31 (16.1) 68.40 (20.9) 69.20 (18.4) 67.96 (19.9) 68.56 (17.4) Children with cancer Mean (SD) 0.00/6.7 0.00/18.8 0.00/11.3 0.00/4.2 0.38/10.9 0.00/2.6 0.00/8.5 0.00/19.8 0.00/12.9 0.00/5.1 0.00/11.4 0.00/4.0 %Floor/%Ceiling 284 284 284 284 284 284 213 216 215 216 216 216 n 78.03 (16.5) 85.33 (15.4) 76.90 (16.6) 80.09 (17.6) 82.18 (17.6) 80.74 (16.9) 83.81 (16.2) 88.16 (17.6) 80.25 (15.8) 84.20 (17.3) 86.33 (16.1) 84.72 (16.4) Healthy children Mean (SD) 0.00/29.9 0.00/38.0 0.00/33.8 0.00/15.1 0.00/15.8 0.00/5.6 0.00/31.9 0.00/39.8 0.00/37.2 0.00/16.2 0.00/18.5 0.00/6.5 %Floor/%Ceiling 0.87 0.70 0.73 0.84 0.92 0.87 1.15 0.57 0.68 0.86 1.03 0.96 Effect size* SD: standard deviation *Effect size for differences in means are designated as small (0.20-0.49), medium (0.50-0.79), and large (0.80 and above) in magnitude †All scale scores for the children with caner are significant differences from healthy children (p 12 months): self- and proxy-report (bold) Communication Perceived physical appearance Cognitive problems Worry Treatment anxiety Procedural anxiety Nausea Pain and hurt Cancer scale School functioning Social functioning Emotional functioning Psychosocial functioning Physical functioning Total score Generic Scale Scales 110 157 110 157 110 157 110 157 110 155 108 154 110 154 110 155 110 157 110 157 110 157 110 157 110 157 86 107 n 70.23 (20.54) 74.68 (19.03) 63.92 (22.36) 66.81 (18.29) 63.17 (28.31) 62.42 (22.63) 68.77 (23.48) 62.85 (20.69) 66.59 (23.24) 59.13 (22.00) 70.09 (25.65) 72.11 (23.96) 74.85 (19.48) 77.21 (16.90) 72.66 (19.11) 71.18 (22.83) 65.42 (16.98) 62.33 (16.70) 62.57 (21.08) 61.55 (18.67) 67.94 (17.53) 63.07 (19.40) 64.71 (19.54) 59.82 (24.58) 77.97 (17.48) 72.02 (20.68) 58.47 (19.89) 57.96 (19.30) mean (SD) Child On-treatment (a) 26 35 26 35 26 35 26 35 26 35 26 34 26 34 26 35 26 35 26 35 26 35 26 35 26 35 20 26 75.35 (20.19) 77.81 (21.45) 78.72 (19.11) 72.34 (23.05) 70.29(25.25) 64.71 (25.39) 72.11 (26.23) 68.05 (24.38) 70.33 (28.10) 60.78 (24.43) 73.83 (30.02) 74.44 (29.12) 76.98 (22.17) 74.93 (20.55) 73.27 (18.40) 75.29 (24.52) 67.14 (18.05) 65.92 (19.43) 67.12 (18.25) 66.18 (20.63) 67.23 (19.77) 66.04 (17.36) 67.36 (22.81) 68.40 (21.82) 75.03 (18.24) 72.26 (18.52) 60.35 (18.55) 60.80 (22.25) Child off-treatment (b) ≤ 12 months n Mean (SD) 66 74 66 74 66 74 66 74 66 72 66 72 66 73 65 72 66 74 66 74 66 74 66 74 66 74 59 62 78.66 (22.47) 82.12 (20.60) 83.20 (18.59) 81.72 (16.14) 73.33 (24.90) 76.26 (24.87) 73.84 (20.64) 72.97 (23.38) 71.32 (25.61) 67.20 (24.74) 71.75 (29.45) 74.25 (26.92) 79.65 (18.34) 75.77 (17.49) 70.98 (22.75) 72.04 (22.38) 73.69 (16.19) 71.22 (17.92) 76.26 (19.24) 75.51 (21.15) 72.20 (18.92) 68.87 (18.56) 73.64 (20.16) 70.71 (18.44) 79.30 (15.68) 75.16 (18.79) 65.18 (23.09) 62.94 (24.35) Child off-treatment (c) > 12 months n Mean (SD) a < c* a < c** a < c* a < c** a < b**, a < c*** a < c***, b < c* a < c* a < c***, b < c* a < c** a < b*, a < c*** a < c** a < c*** a < c***, b < c* a < c***, b < c* Difference 3.38 3.57 19.22 16.50 3.12 8.74 1.05 5.46 0.83 3.06 0.22 0.23 1.24 0.32 0.18 0.46 5.04 6.58 9.53 12.70 1.30 2.42 4.05 6.44 0.59 0.65 1.81 1.08 F 0.036 0.029 0.000 0.000 0.046 0.000 0.352 0.005 0.438 0.049 0.804 0.791 0.291 0.723 0.832 0.633 0.007 0.002 0.000 0.000 0.275 0.091 0.019 0.002 0.556 0.524 0.167 0.342 P Value *P < 0.05, **P < 0.01, ***P < 0.001 based on Tukey Honestly Significantly Different post hoc analysis Emotional functioning P1 Physical functioning E4 E3 E2 E1 P8 P7 P6 P5 P4 P3 P2 Item Subscale 666 338 825 -.031 828 -.020 804 -.123 721 185 373 -.043 620 620 527 571 -.018 -.049 026 093 136 225 -.005 205 Factor 000 700 -.037 779 047 756 274 807 468 693 -.002 658 139 345 228 073 070 225 188 225 217 182 002 148 Factor 153 078 127 250 -.029 -.093 -.052 -.116 091 153 203 292 -.103 055 059 108 830 -.129 710 -.021 688 012 263 050 Factor 065 041 101 092 -.135 168 -.249 157 241 -.046 477 082 172 -.189 121 183 165 048 026 179 105 007 -.013 726 Factor 131 064 -.021 121 100 025 004 210 -.024 190 094 256 023 028 114 259 082 777 102 780 135 748 071 377 Factor 126 005 123 243 -.022 042 036 062 -.034 151 051 074 072 186 -.157 068 130 009 035 -.163 121 134 755 -.070 Factor Table PedsQL 4.0 Generic Core Scales factor loadings for child self- and parent proxy-report in children with cancer Percent Variance Eigenvalue School functioning Social functioning Sc5 Sc4 Sc3 Sc2 Sc1 S5 S4 S3 S2 S1 E5 173 200 227 202 160 -.026 -.025 -.155 199 -.203 025 017 -.207 161 -.038 -.040 -.068 179 154 860 030 111 6.744 7.457 25.320 28.074 -.206 143 697 152 848 -.017 695 040 412 039 668 254 378 078 031 -.014 187 041 096 135 044 233 2.844 3.554 10.364 11.103 305 -.082 209 700 005 367 217 563 781 506 265 756 006 134 255 187 089 181 021 -.045 253 015 2.208 2.453 9.602 10.665 -.048 555 179 293 009 777 126 217 256 089 318 092 716 -.102 802 189 600 052 040 181 095 -.119 1.878 1.956 7.164 8.071 -.084 407 -.302 -.158 069 058 216 232 -.064 268 198 044 -.059 138 021 039 194 047 923 -.012 908 110 1.579 1.699 5.865 6.517 638 -.268 199 -.128 178 124 -.271 176 009 074 131 003 069 664 -.170 521 072 833 -.094 290 152 813 1.145 1.182 3.977 5.138 Note: Bold values indicate the largest factor loading for each item In each cell, child self-report loading are shown above and the parent proxy-report loading are shown below in italics Extraction Method: Principle Component Analysis Rotation Method: Oblimin with Kaiser Normalization Total Variance Explained for child self-report: 62.3%; for Parent Proxy-report: 69.6% Treatment anxiety Procedural anxiety Nausea P1 Pain and hurt TA2 TA1 PA3 PA2 PA1 N5 N4 N3 N2 N1 P2 Item Subscale 034 -.009 136 097 854 158 657 004 789 199 668 052 821 190 011 766 050 860 -.057 848 350 821 071 864 Factor 104 023 206 075 115 835 028 573 018 827 -.183 731 -.008 727 159 -.114 043 156 137 035 840 024 795 290 Factor 008 029 072 017 121 -.057 -.094 080 082 -.013 038 -.123 145 089 042 043 -.030 030 212 -.044 040 085 127 092 Factor 023 -.160 049 180 039 087 044 -.038 -.009 156 019 070 114 026 866 -.061 876 -.022 917 -.095 158 248 030 096 Factor 689 066 714 091 -.060 -.086 253 021 107 -.057 032 075 049 244 061 070 055 -.156 011 -.007 135 114 135 210 Factor 150 009 -.171 056 -.173 -.079 005 022 -.094 069 111 147 138 080 103 -.047 -.100 070 -.069 062 009 105 069 157 Factor Table PedsQL 3.0 Cancer Module factor loadings for child self- and parent proxy-report in children with cancer 071 533 031 789 -.123 016 007 -.046 -.020 134 -.040 343 -.077 093 -.133 184 035 361 099 005 133 045 193 -.082 Factor -.068 -.100 061 -.080 199 -.033 -.072 -007 130 219 073 104 Factor Communication Perceived physical appearance Cognitive problems Worry C1 A3 A2 A1 CP5 CP4 CP3 CP2 CP1 W3 W2 W1 TA3 156 888 049 033 253 021 066 -.054 -.197 196 004 112 -.137 -.013 -.002 223 -.204 061 005 041 024 060 213 -.079 123 009 861 155 013 043 172 024 021 099 -.030 137 -.165 051 -.041 -.004 221 -.044 134 085 820 161 757 -.094 857 -.106 101 131 011 116 622 118 751 014 807 078 012 849 -.040 900 -.198 614 006 742 -.109 794 -.140 246 046 -.162 166 030 182 074 186 245 -.011 561 176 775 125 775 120 -.051 -.034 034 011 191 -.119 002 -.073 155 050 088 050 179 -.198 142 118 044 293 046 127 040 033 142 004 020 031 273 -.083 070 391 243 085 180 177 176 -.087 112 -.215 212 -.180 079 159 843 -.101 041 028 060 044 -.022 058 184 882 087 863 219 631 091 706 279 665 -.053 -.024 767 -.073 637 036 666 020 311 -.021 -.099 049 063 083 191 062 004 105 163 079 073 120 172 098 -.057 074 -.160 -.192 270 -.094 -.062 033 -.030 060 -.016 611 -.047 013 076 -.022 109 -.009 138 038 201 003 -.095 -.035 -.083 024 010 113 6.548 8.682 24.253 32.157 -.107 181 -.005 -.144 4.303 5.225 13.936 15.647 078 193 281 110 3.635 3.725 9.462 10.091 040 175 098 040 2.319 2.756 7.587 8.613 148 551 048 743 2.074 2.142 7.182 8.081 100 -.148 035 105 1.771 1.843 6.560 6.715 -.041 046 -.188 061 1.340 1.447 4.962 5.246 4.057 1.096 742 905 Note: Bold values indicate the largest factor loading for each item In each cell, child self-report loading are shown above and the parent proxy-report loading are shown below in italics Extraction Method: Principle Component Analysis Rotation Method: Oblimin with Kaiser Normalization Total Variance Explained for child self-report: 78.0%; for Parent Proxy-report: 86.6% Percent Variance Eigenvalue C3 C2 0.461** 0.382** 0.410** 0.494** 0.535** 0.497** 0.447** 0.298** 0.237** 0.860** 0.798** 0.729** 0.513** 0.479** 0.365** 0.326** 0.396** anxiety anxiety Nausea (N) Procedural (PA) Treatment (TA) Worry (W) 0.354** Communication (C) 0.291** 0.295** 0.253** 0.228** 0.324** 0.290** 0.314** 0.413** 0.375** 0.605** 0.327** 0.647** 0.506** 0.818** Em 0.271** 0.285** 0.327** 0.239** 0.273** 0.272** 0.291** 0.386** 0.523** 0.359* 0.507** 0.631** 0.530** 0.744** Soc 0.231** 0.219** 0.424** 0.210** 0.204** 0.228** 0.292** 0.342** 0.305** 0.413** 0.293** 0.677** 0.486** 0.620** Sch 0.270** 0.253** 0.086 0.281** 0.189* 0252** 0.220** 0.442** 0.356** 0.203** 0.231** 0.298** 0.429** 0.476** P 0.206** 0.287** 0.303** 0.316** 0.434** PA 0.297** 0.118 0.182* 0.139 0.281* 0.239** 0.032 0.321** 0.184* 0.251** 0.203** 0.434** 0.349** 0.406** 0.235* 0.228** 0.229** 0.274** 0.136 0.210** 0.322** 0.278** 0.428** N 0.274** 0.311** 0.354** 0.329** 0.377** 0.353** 0.465** 0.283** 0.277** 0.266** 0.370** 0.303** 0.395** W 0.293** 0.042 0.335** 0.349** 0.371** 0.420* 0.483** 0.365** 0.273** 0.297** 0.264** 0.224** 0.254** 0.280** 0.380** TA 0.251** 0.388** 0.308* 0.214** 0.341** 0.174* 0.238* 0.305** 0.394** 0.248** 0.205** 0.333** 0.245** 0.336** CP 0.267** 0.322** 0.398** 0.357** 0.260** 0.319** 0.174* 0.341** 0.195** 0.233** 0.239** 0.395** 0.266** 0.304** A 0.318** 0.199** 0.276** 0.219** 0.285** 0.230** 0.120 0.282** 0.118 0.220** 0.194* 0.257** 0.271** 0.318** C Note: scores obtained by child above the diagonal; scores obtained by parent below the diagonal; correlation between scores of the child and parent on the diagonal Correlation values between the PedsQL 4.0 Generic Core Scales Total Score with the PedsQL 3.0 Cancer Module Scales are set in boldface 0.311** 0.329** 0.249** 0.315** 0.213** 0.376** 0.365** 0.348** 0.285** 0.337** 0.869** 0.848** 0.336** Cognitive problems CP) Appearance (A) 0.278** 0.302** 0.785** 0.585** 0.905** 0.591** 0.501** 0.878** 0.853** Physical functioning (Ph) Psychosocial functioning (Psy) Emotional functioning (Em) Social functioning (Soc) School functioning (Sch) Pain and hurt (P) 0.826** Psy 0.493** PH Total Score (Tot) Tot Table Intercorrelations among PedsQL Scales and correlation between scores of the child and parent Correlation values between the scores of child and parent are underlined All correlations present significance levels when *p < 0.05 and **p