Inadequate social support and household material hardship among children with pediatric acute lymphoblastic leukemia: A report from the Children's oncology group Trial AALL1731

Abstract Introduction: Parents of children with cancer living in poverty experience higher rates of psychological distress during childhood cancer treatment and existing psychosocial interventions have been less effective for this population. High parental distress predicts poor mental health for parents and children in survivorship and impairs cognitive bandwidth and executive function–key for decision-making and treatment adherence. Household material hardship ([HMH] food, housing, utility or transportation insecurity), a concrete poverty measure, is independently associated with 2 to 5 times the risk of severe psychological distress among parents of children with acute lymphoblastic leukemia (ALL). Identifying risk factors for HMH that may be modifiable with supportive care interventions is critical to improve disparities in parental distress. Social support—the perceived availability of emotional and tangible support from family, peers and the community—has been linked to better coping, lower psychological distress, and improved health-related outcomes in adult oncology. Its relationship to HMH in childhood cancer has not been explored. We conducted a secondary analysis of data from the Children's Oncology Group (COG) trial AALL1731, the first COG ALL trial to systematically collect parent-reported social determinants of health, examining the association between social support and HMH at start of ALL therapy. Methods: Children ages 1-9 with de novo NCI standard risk B-ALL, who spoke English, Spanish or French and enrolled on AALL1731 (NCT03914625) at a US or Canadian site from September 2020 to July 2024 could opt-in to a longitudinal, correlative “Household Material Hardship and Neurocognitive Late Effects” study. Parents/guardians of participants completed a 75-item survey at 4-timepoints: baseline (during Induction), start of maintenance, end of therapy, and 1-year post-therapy. This secondary, interim analysis explored the association between baseline parent-reported social support and baseline HMH. The primary exposure of interest was social support as measured by the validated 8-item Medical Outcomes Study Social Support Survey (mMOS-SSS)—which uses a Likert scale to query how often someone is available to help you in domains of emotional (e.g. turn to for suggestions about a personal problem) and concrete (e.g. prepare meals) supports—dichotomized as inadequate social support (mMOS-SSS <70) vs adequate (≥70). The primary outcome of HMH was defined as present (at least one of food, housing, utility or transportation insecurity) vs absent. Univariable and multivariable analyses adjusting for child race/ethnicity, age, sex, insurance, primary language, marital status, and parent education were performed. Results: A total of 1487 participants contributed data from 179 sites; of these 1067 (72%) had evaluable mMOS-SSS and HMH data to comprise the analytic cohort. Participants were mostly mothers (76%), married (79%), and preferred English as a primary language (81%). Half of patients (52%) were Non-Hispanic White, 25% Hispanic, and 7% Black; 330 (31%) reported inadequate social support. In unadjusted logistic regression, participants with inadequate social support had 4.1-times (95% CI 3.1, 5.4) higher odds of HMH at baseline. Upon adjustment, those with inadequate social support had 2.9-times (95% CI 2.1, 3.9) higher odds of HMH. Analyses of associations between baseline social support and longitudinal development of HMH and parent psychological distress are pending mature data. Conclusion: Inadequate social support at the start of ALL therapy is independently associated with the presence of HMH—a known risk factor for severe parent psychological distress during cancer treatment. These data identify social support as a potential target for interventions to improve parent and child well-being. Parents of children with ALL face substantial and prolonged psychosocial burdens due to financial, logistical, and emotional strain over the >2-year care trajectory. We will investigate whether adequate social support protects against financial toxicity (including the development of new HMH) and parent psychological distress during treatment once data mature. Future work will include partnering with parents and psychosocial providers to adapt existing models of social support interventions (individualized psychobehavioral interventions, peer-based interventions, and community-based interventions) for the pediatric oncology setting.