Pediatric cancer in western China: a cross-sectional analysis of cognitive impairment

Abstract

Background and aims

Cancer-Related cognitive impairment is a prevalent complication in cancer children. Nonetheless, little is known about the risk factors for cognitive impairment in this group. The aim of this study was to analyze and evaluate the risk factors for cognitive impairment in children and adolescent cancer patients in western China.

Methods

A cross-sectional study was conducted in a tertiary hospital in western China. A total of 105 cancer children and adolescents were enrolled in the study. Cognitive function was assessed using the Six-subtest short-form of Wechsler Intelligence Scale for Children-four Edition. Demographic and clinical data were collected using a questionnaire. Binary logistic regression analysis was used to identify the risk factors for cancer-related cognitive impairment.

Results

The mean age of the patients was 10.04 years, and 60% were male. The incidence rate of Cancer-Related cognitive impairment was 39%. Binary logistic regression analysis showed that gender (OR = 0.11, 95% CI: 0.02–0.48), disposition (OR = 3.15, 95% CI: 0.88–11.37), course of disease (OR = 3.01, 95% CI: 1.56–5.83), sleep duration (OR = 0.48, 95% CI: 0.31–0.76), chemotherapy (OR = 19.46, 95% CI: 1.20-315.24), and father’s education level (OR = 0.04, 95% CI: 0.01–0.18), were independent risk factors for Cancer-Related cognitive impairment.

Conclusions

High prevalence of cognitive impairment among pediatric cancer patients. Key influencing factors included clinical factors, demographic characteristics, and sleep duration. These findings underscore the critical need to integrate routine cognitive and sleep assessments into standard clinical care. Early intervention targeting these modifiable factors, particularly sleep quality, is essential for mitigating cognitive decline in this vulnerable population.

Introduction

Malignant tumor is one of the main diseases that affect the health of children and adolescents. Approximately 400,000 children and adolescents worldwide, ages 0 to 19, are affected with malignant tumor disorders each year [1]. In China, about 40,000 children are diagnosed with malignant tumor every year, which has caused great social burden [2, 3]. The number of children who survived malignant tumors rises annually due to the continuous progress in medicine technology [4]. In developed countries, the five-year survival rate of children with malignant tumors has exceeded 80% [5]. On the other hand, a greater amount of children will experience the side effects of the disease and its various treatments. Cognitive impairment is a frequent childhood cancer complication that has a lasting influence on children.

Cancer-Related Cognitive Impairment (CRCI) is a complication caused by various tumors and anti-cancer treatments such as chemotherapy, radiotherapy, and surgery [6]. The major symptom of this disorder is a reduction or loss of cognitive abilities, including executive function, memory, attention, language expressiveness, and problem-solving speed [7–9]. Up to 35–60% of children with cancer have CRCI [10]. This has a significant negative impact on the children’s quality of life, as seen by declining cognitive scores, sluggish scholastic progress, compromised physical function, and decreased social adaptation [11–13]. If CRCI occurs in children in a short period of time, it may lead to a decrease in treatment compliance and worsening psychological status [14], resulting in adverse prognosis. These kids’ cognitive reserve may also decline with maturity, raising their risk of memory problems and early-onset dementia [15]. Therefore, in order to enhance the prognosis of children with malignant tumors, emphasis must be given to the issue of cognitive impairment.

Previous studies have demonstrated that a variety of physiological, psychological, and medical treatment-related characteristics are associated with a higher risk of CRCI in children and adolescents with malignant tumors. Research has indicated [15] that intrathecal chemotherapy and cranial radiation therapy are two high-risk factors for CRCI in children. Krull KR [16] found that children cancer survivors who received whole brain radiotherapy had severe damage in memory (54.9%), processing speed (66.3%), and executive function (68.3%). Reuter et al. [42] have demonstrated that neurotransmitters closely related to psychology, such as serotonin, are of great significance to cognitive development in children. Tham [17] reviewed 20 studies and pointed out that sleep quality has a positive impact on enhancing cognitive function in children. The study of Albee [18] emphasized that a harmonious family atmosphere is beneficial for children to master more advanced social skills, while adverse family relationships may exacerbate emotional disorders in patients, leading to negative psychology and negative emotions, thereby increasing the risk of CRCI. Nevertheless, these studies lack a thorough systematic analysis and instead concentrate more on the effects of individual influencing factors on CRCI. Simultaneously, the circumstances and contributing factors to cognitive impairment may also vary depending on the geographical location and cultural background. But this research has not received enough attention in China, and further exploration is needed.

Building upon our previous study in preschool children with cancer [19], which used the Ages & Stages Questionnaire and identified several factors influencing neurocognitive function, this study extends the focus to school-aged children and adolescents. We employed the Wechsler Intelligence Scale for Children, a more comprehensive and psychometrically advanced tool, to provide detailed assessment of cognitive domains such as executive function, working memory, and processing speed. This progression allows for a deeper understanding of cognitive outcomes across different developmental stages in pediatric cancer patients.

The purpose of this study was to investigate the prevalence of cognitive impairment in children with cancer and to thoroughly examine the risk factors of cognitive impairment in children with malignant tumors at varying levels. The research carried out in a top-three children’s hospital in the western region of China, with the goal of offering helpful information for the prevention and treatment of cognitive impairment related to childhood malignant tumors. The purpose of this research is to give data that will help clinical medical professionals and associated researchers create tailored intervention plans that will effectively prevent or lessen the incidence of cognitive impairment in children with cancer.

Materials and methods

Study participants

From September to November in 2023, convenience sampling method was used to select the subjects from the Department of Neurosurgery, Department of Oncology, Department of Hematology, and outpatient department of a children’s hospital in Chongqing, National Center for Children’s Health and Disease Clinical Medical Research. This approach was necessitated by the limited and critically ill pediatric tumor population, making probability sampling impractical. While enhancing feasibility, we acknowledge potential generalizability limitations. To mitigate bias, stringent inclusion/exclusion criteria were applied and data were collected over a focused period to better represent the hospital’s patient flow.

Inclusion criteria: ① Diagnosed with malignant tumor (including but not limited to central nervous system tumor, hematological tumor, etc.) according to the guidelines for diagnosis and treatment of childhood malignant tumor; ② Age between 6 and 16 years old; ③ The children and their caregivers have no severe mental illness and no major psychological stress in the recent period; ④ Have informed consent, voluntary participate, and have speech communication ability and communication ability. Exclusion criteria: ① Severe physical disabilities; ② Caregivers with hearing impairment or cognitive impairment, mental illness patients; ③ Children or guardians require withdrawal during the study.

Research tools

General information questionnaire

Through a review of relevant domestic and foreign literature, discussion within the research team and correspondence with oncologists, combined with the characteristics of malignant tumors, a general data questionnaire was developed, including sociodemographic data such as the gender of the child, age of the child, number of hospitalizations, age at initial diagnosis, educational level of the primary caregiver, place of residence, child disposition, and parenting style (including authoritarian, autocratic, and indulgent styles, with corresponding explanations provided for each option to allow respondents to choose based on their actual situation), as well as disease and treatment-related data such as surgical interventions received, radiotherapy and chemotherapy, and use of chemotherapeutic agents and laboratory test results.

Wechsler intelligence scale for children-fifth edition (WISC-IV) Chinese version (short form)

The “six-subtest short form” of the fourth edition of the Wechsler Intelligence Scale for Children (Chinese version) [20] is used as a cognitive ability test scale, which is suitable for assessing cognitive abilities of children and adolescents aged 6 to 16 years and 11 months. The Wechsler scales represent a widely adopted international standard for cognitive assessment. The short form was selected to reduce testing time and improve compliance in pediatric patients with tumors, who may experience fatigue or distress during lengthier evaluations. This abbreviated version demonstrates high reliability (Cronbach’s = 0.92) and correlates strongly with the full-scale IQ. It provides a Full-Scale IQ score classified as follows: ≥90 (normal), 80–89 (lower), 70–79 (marginal), and ≤ 69 (very low).

Spence Children’s Anxiety Scale-Short version (SCAS-S)

There are 19 items in total [21], which are divided into 5 dimensions: social anxiety, separation anxiety, panic disorder, fear of physical harm and generalized anxiety. The scale uses a 4-point rating scale (1 = never, 2 = sometimes, 3 = often, 4 = always). The higher the scale score, the more severe the anxiety level. The Chinese version of SCAS-S was validated by Liu et al [22]. in a psychometric study involving 527 children aged 9–12 years in China. The results demonstrated a well-fitting five-factor structure, good cross-gender measurement equivalence, and expected correlations with related variables such as bullying, emotional regulation, and perceived parental marital conflict. The overall Cronbach’s α was 0.86, and all subscales showed acceptable internal consistency (α > 0.6; mean inter-item correlation between 0.34 and 0.41), supporting its reliability and validity in measuring anxiety among school-aged children in the Chinese context. In this study, the Cronbach’s α of the SCAS-S was 0.902. Due to sample size considerations, the scale was analyzed using a unidimensional approach.

Sleep disturbance scale for children (SDSC)

There are 26 items in total [23], which are rated using the Likert 5-point scale according to the frequency of occurrence. The scores are as follows: 1 point = never, 2 points = 1–2 times per month, 3 points = 1–2 times per week, 4 points = 3–5 times per week, and 5 points = always. The total score of each part is the sum of the scores, and a score greater than 39 can be considered as sleep disorder. The SDSC scale can reflect some of the most common sleep disorders affecting children. The Cronbach’s coefficient of the SDSC scale is 0.79. The Chinese version of this scale was validated by CHEN et al. [24] in a study across five cities in Fujian Province, China, involving 370 children. Their results showed that the Chinese version of the SDSC has high internal consistency (Cronbach’s α = 0.87) and good validity, supporting its applicability for comprehensively assessing sleep disturbances in preschool children and facilitating early screening of sleep-related issues in clinical practice.

The method of data collection

Children were tested one-on-one using the WISC-IV by qualified and highly trained staff members. After the test, the raw scores were entered into the Wechsler Intelligence Test officially authorized website to calculate the estimated values of Full scale intelligent quotient(FSIQ), Verbal comprehension, and Perceptual reasoning, which were used to reflect children’s cognitive function. In this study, children with FSIQ below 90 were identified as having cognitive impairments. In addition to gathering the case data from the hospital information system, researchers assisted parents of children in completing the remaining scales on their own while they were there. The data was double-checked and then entered into Excel software to complete data collation.

Statistical methods

The statistical analysis was carried out using SPSS26.0 software. For measurement data with normal distribution, they were expressed as 𝑥±𝑠, the comparison between groups was conducted by independent samples T-test, and multiple groups were compared by one-way analysis of variance (ANOVA). For measurement data with non-normal distribution, they were described as M(𝑝25-𝑝75), and the comparison between groups was conducted by Mann-Whitney U test, Multiple groups were compared by Kruskal-Wallis H test. Count data were presented as case numbers and percentages (%), and the comparison between groups was performed by Chi-square test. The Wilcoxon rank sum test was used to test for multi-class variables pertaining to groups. Multiple factors analysis was carried out by binary Logistic stepwise regression analysis to test the related factors of cognitive dysfunction in children with malignant tumors. The P < 0.05 indicated significant differences between groups.

Result

The basic information of children with malignant tumors and their caregivers

The 105 children and adolescent (10.04 ± 2.88 years) ranged in age from 6 to 16 years, with 63 boys and 42 girls. The disease continued from 0 to 5.58 years (0.81 ± 1.08 years) after the initial diagnosis, which was made at the age of 1–16 years (9.23 ± 3.15). According to the diagnosis, there were 45 cases of other malignancies, 39 cases of blood tumors, and 21 cases of nervous system tumors. Of them, 93 cases had chemotherapy (0–32 times, with an average of 6.49 ± 6.56 times, including 30 cases of intrathecal chemotherapy), 14 cases had radiation, and 49 cases underwent surgery. There were between 0 and 34 hospitalizations (7.03 ± 6.88 occasions). There were 72 parents who were the primary caretakers, and additional (n = 33). The educational level of the fathers was: primary school and below (n = 5), junior high school and below (n = 39), high school and below (n = 35), and university and above (n = 26). The educational level of the mothers was: primary school and below (n = 3), junior high school and below (n = 45), high school and below (n = 36), and university and above (n = 21). Family monthly income: <3000 yuan (n = 38), 3000–5000 yuan (n = 57), > 5000 yuan (n = 10).

WISC-IV score

Table 1: Scores of the Wechsler Intelligence Scale for Children-6 short version. The lowest composite score is “Verbal Comprehension” (89.31 ± 16.78). Among the subtests, the lowest scores are “Similarities” (7.73 ± 2.74), “Comprehension” (8.65 ± 3.30), and “Number Recall” (8.55 ± 2.14). This study shows that children with malignancies have lower cognitive abilities, with a total IQ score of (92.89 ± 11.31) points. By comparing the WISC-IV composite scores of 105 children with malignancies with the Chinese norms, we found that the overall IQ and Verbal Comprehension scores of these children were significantly lower than the norm (P < 0.001; single sample t-test). Furthermore, by comparing the three composite scores, we found that the average Verbal Comprehension score was significantly lower than the average overall IQ and Perceptual Reasoning scores (P < 0.05, t-test), indicating that Verbal Comprehension is a weak point in the cognitive domain of children with malignancies; while the average Perceptual Reasoning score was significantly higher than the Verbal Comprehension score (P < 0.001, t-test), suggesting that children with malignancies have advantages in the cognitive domain of Perceptual Reasoning. By comparing the WISC-IV subtest scores with the norms, we found that the scores of Similarities, Comprehension, and Number Recall were significantly lower (P < 0.001, t-test), which supports the poor performance in Verbal Comprehension and suggests that children with malignancies have unique cognitive characteristics.

Table 1.

Comparison of WISC-IV and subtest scores of children with malignant tumors with normal values of Chinese norms (n = 105)

Assessment	Mean(SD)	Standardized Scores(Mean)	P value
Index
Full scale intelligent quotient	92.89 ± 11.31	100 ± 15	P<0.001
Verbal comprehension	89.31 ± 16.78	100 ± 15	P<0.001
Perceptual reasoning	99.27 ± 11.68	100 ± 15	P=0.522
Subtest
Similarities	7.73 ± 2.74	10 ± 3	P<0.001
Comprehension	8.65 ± 3.30	10 ± 3	P<0.001
Block design	10.32 ± 2.14	10 ± 3	P=0.124
Matrix reasoning	9.41 ± 2.94	10 ± 3	P=0.042
Digit span	8.55 ± 2.14	10 ± 3	P<0.001
Coding	9.41 ± 2.76	10 ± 3	P=0.031

Single factor analysis of cognitive impairment in children with malignant tumor

The comparison of cognitive impairment among children with malignant tumors in the aspects of white blood cell count, platelet count, red blood cell count, hemoglobin, neutrophil percentage, uric acid value, basic disease history, family history, disease category, surgical treatment, platinum-based chemotherapy drugs, vincristine, methotrexate, intrathecal chemotherapy, family residence, exercise status, cognitive activity status and internet use time is all P > 0.20. The results of univariate analysis with P < 0.20 are shown in Table 2.

Table 2.

Univariate analysis of cognitive impairment in children with malignant tumor (n = 105)

Variable	Total (n = 105)	cognitive		t/Z/	P
		0 (n = 64)	1 (n = 41)
Age at first diagnosis	9.23 ± 3.15	9.91 ± 2.93	8.16 ± 3.22	t = 2.864	0.005
Course of disease	0.42 (0.17–0.92)	0.37 (0.17–0.67)	0.67 (0.25–1.17)	Z=−2.887	0.004
Age	10.25 (7.00–12.25)	10.67 (8.27–12.35)	8.67 (6.67–12.00)	Z=−1.741	0.082
Frequency of chemotherapy	5.00 (2.00–8.00)	3.00 (1.00–7.00)	6.00 (4.00–11.00)	Z=−3.074	0.002
Number of hospitalizations	6.00 (3.00–10.00)	5.00 (2.00–9.00)	7.00 (5.00–16.00)	Z=−2.700	0.007
SCASS	24.00 (23.00–25.00)	23.00 (22.00–24.00)	25.00 (24.00–26.00)	Z=−4.257	< 0.001
Sleep duration	8.00 (7.00–9.00)	8.00 (7.75–9.00)	8.00 (5.00–9.00)	Z=−3.032	0.002
Age at first diagnosis group,				χ²=5.95	0.051
0–6	17 (16.19)	6 (9.38)	11 (26.83)
6–12	64 (60.95)	41 (64.06)	23 (56.10)
12–18	24 (22.86)	17 (26.56)	7 (17.07)
Age group				χ²=0.66	0.416
0–12	72 (68.57)	42 (65.62)	30 (73.17)
12–18	33 (31.43)	22 (34.38)	11 (26.83)
Gender				χ²=2.161	0.142
Female	42 (40)	22 (34.38)	20 (48.78)
Male	63 (60)	42 (65.62)	21 (51.22)
Surgical				χ²=2.404	0.121
No	56 (53.33)	38 (59.38)	18 (43.90)
Yes	49 (46.67)	26 (40.62)	23 (56.10)
Radiotherapy				χ²=7.117	0.008
No	91 (86.67)	60 (93.75)	31 (75.61)
Yes	14 (13.33)	4 (6.25)	10 (24.39)
Chemotherapy				χ²=4.012	0.045
No	12 (11.43)	11 (17.19)	1 (2.44)
Yes	93 (88.57)	53 (82.81)	40 (97.56)
sleep disorder				χ²=16.813	< 0.001
No	79 (75.24)	57 (89.06)	22 (53.66)
Yes	26 (24.76)	7 (10.94)	19 (46.34)
Parenting style				χ²=11.487	0.003
Authoritative type	31 (29.52)	25 (39.06)	6 (14.63)
Autocratic type	21 (20)	15 (23.44)	6 (14.63)
Doting type	53 (50.48)	24 (37.50)	29 (70.73)
Monthly household income				χ²=5.253	0.072
3000–5000	38 (36.19)	18 (28.12)	20 (48.78)
5000–10,000	57 (54.29)	38 (59.38)	19 (46.34)
>10,000	10 (9.52)	8 (12.50)	2 (4.88)
financial burden				χ²=3.166	0.075
No	28 (26.67)	21 (32.81)	7 (17.07)
Yes	77 (73.33)	43 (67.19)	34 (82.93)
Father’s education level				χ²=24.913	< 0.001
Primary school or below	9 (8.57)	1 (1.56)	8 (19.51)
Junior High School or below	38 (36.19)	16 (25.00)	22 (53.66)
High School or below	33 (31.43)	27 (42.19)	6 (14.63)
University and above	25 (23.81)	20 (31.25)	5 (12.20)
Mother’s education level				-	0.001
Primary school or below	4 (3.81)	1 (1.56)	3 (7.32)
Junior High School or below	46 (43.81)	20 (31.25)	26 (63.41)
High School or below	35 (33.33)	28 (43.75)	7 (17.07)
University and above	20 (19.05)	15 (23.44)	5 (12.20)
Disposition				-	0.002
Extroversion	55 (52.38)	42 (65.62)	13 (31.71)
Centralization	8 (7.62)	3 (4.69)	5 (12.20)
Introvert	42 (40)	19 (29.69)	23 (56.10)

Multifactorial analysis of cognitive impairment in children with malignant tumor

Using variables with P < 0.20 in univariate analysis as independent variables, logistic regression analysis was performed with cognitive impairment classification as the dependent variable (non-cognitive impairment = 0, cognitive impairment = 1). The results showed that duration of illness (original data), sleep time (original data), gender (female = 0, male = 1), chemotherapy (no = 0, yes = 1), father’s educational level (set dummy variables with primary school and below as control), and disposition (set dummy variables with extroversion as control) entered the regression equation, as shown in Table 3.

Table 3.

Multifactorial analysis of cognitive impairment in children with malignant tumor

Variables	Beta	S.E	Z	P	OR (95%CI)
Course of disease	1.10	0.34	3.28	0.001	3.01 (1.56–5.83)
Sleep duration	−0.73	0.23	−3.16	0.002	0.48 (0.31–0.76)
Gender
female					1.00 (Reference)
male	−2.23	0.77	−2.91	0.004	0.11 (0.02–0.48)
Chemotherapy
No					1.00 (Reference)
Yes	2.97	1.42	2.09	0.037	19.46 (1.20–315.24)
Father’s education level
Primary school or below					1.00 (Reference)
Junior High School or below	−3.13	1.52	−2.06	0.040	0.04 (0.00–0.86)
High School or below	−6.12	1.80	−3.40	< 0.001	0.00 (0.00–0.07)
University and above	−5.14	1.76	−2.93	0.003	0.01 (0.00–0.18)
Disposition
Extroversion					1.00 (Reference)
Centralization	3.68	1.28	2.88	0.004	39.82 (3.24–490.02)
Introvert	1.15	0.65	1.76	0.079	3.15 (0.88–11.37)

Discussion

This study identified a 39% prevalence of cognitive impairment among pediatric cancer patients, a finding consistent with international reports [10]. Multiple risk factors were significantly associated with cancer-related cognitive impairment (CRCI), including gender, chemotherapy, disease duration, disposition, sleep duration, and paternal education level. Female gender was identified as a significant risk factor for CRCI[43], corroborating the findings of Gorp et al. [25]. This disparity may be attributed to neurobiological differences, such as smaller white matter volume in females, which could exacerbate treatment-related neural damage [26]. Additionally, hormonal influences including estrogen’s impact on cognitive function may further elevate susceptibility [26]. These results underscore the need for gender-sensitive treatment approaches, such as minimizing neurotoxic chemotherapeutic agents in female patients and implementing closer monitoring of neurocognitive outcomes.

Chemotherapy was confirmed as a major contributor to CRCI. Given that the developing brains of children are particularly vulnerable to neurotoxic insults [27], chemotherapy can significantly impair cognitive function [12]. Although it is methodologically challenging to isolate chemotherapy effects from other treatment modalities (e.g., surgery or radiotherapy), accumulated evidence strongly supports its independent role in CRCI [13, 28, 29]. Treatment protocols should thus be optimized to reduce neurotoxicity risks without compromising efficacy, and regular neuropsychological monitoring should be implemented during chemotherapy.

According to Aarsen [44], a significant risk factor for cognitive impairment in children with cancer is how long the disease has been present. Longer disease duration also elevated CRCI risk, likely because extended illness leads to cumulative treatment exposures—such as repeated chemotherapy or radiotherapy—and prolonged school absence, which impedes cognitive stimulation and social interaction. Increased hospitalization may also promote social isolation and compensatory smartphone use, further restricting social engagement. While advances in cancer therapeutics may shorten treatment durations in the future, comprehensive support—encompassing educational, psychological, and social dimensions—must be provided to children undergoing prolonged treatments to mitigate CRCI risk.

Children with outgoing dispositions tend to exhibit greater psychological adaptability and are less likely to experience anxiety or depression. This may explain the lower incidence of cognitive impairment observed among extroverted individuals in the present study. Given that psychological factors such as anxiety and depression are closely linked to cognitive disorders, personality traits may influence cognitive function through such mechanisms [30, 31]. In contrast to Hooke’s findings regarding the association between anxiety and cognitive function in children with malignancies [45], this study did not identify a significant relationship between anxiety and cognitive impairment. This discrepancy may be attributed to the use of a total anxiety score as a unidimensional variable in the analysis, which may have reduced the sensitivity to detect specific effects, particularly given the relatively small sample size. Future studies should take into account individual differences in children’s psychological profiles, and further research—such as randomized controlled trials and prospective cohort studies—is needed to clarify the relationship between personality traits and cognitive impairment in pediatric cancer patients. Additionally, appropriate psychological and nursing interventions should be implemented to help prevent the development of cognitive impairments.

In children with malignant tumor, the length of sleep has a negative correlation with cognitive function. The research of Clanton et al. [32] shows that short sleep duration and poor sleep quality are closely related to the decline of task efficiency, emotional regulation ability, memory ability, and cognitive function. Cognitive impairment may result from inadequate sleep, which disrupts the neuroendocrine and neurotransmitter systems’ regular functions [46]. Sleep plays a crucial role in the recovery and functioning of brain neurons [33] and significantly influences the severity of CRCI [34]. Cheung et al. [35] demonstrated that frequent nighttime awakenings, early morning waking, and short sleep duration are associated with declines in executive function, cognitive flexibility, and verbal fluency. Therefore, optimizing sleep quality and moderately extending sleep duration may be key to enhancing cognitive function in children with cancer. Parents are encouraged to monitor their children’s sleep patterns closely to ensure adequate rest. In addition, healthcare providers should incorporate sleep assessment into routine cognitive evaluations during treatment to facilitate early detection and intervention.

Additionally, this study discovered that patients raised by fathers with higher education levels had a lower risk of cognitive impairment than patients raised by fathers with lower education level. This finding is consistent with the results of Cr [36] and others. Kesler [37] found that the caregiver’s education level was negatively associated with the white matter and gray matter volume of the brain in cancer patients, and positively associated with the patients’ memory and event processing speed. Higher education also raises one’s social and economic standing, which allows children to have access to better schooling because educated individuals in China typically work in fields requiring more technical know-how. Moreover, the educational level of parents has a significant positive impact on the language memory ability of children [38]. Fathers play a crucial role in their children’s development, and recognizing this may help reduce the risk of cancer-related cognitive impairment (CRCI) in pediatric patients. We encourage fathers to actively engage in supporting their children’s cognitive development—through communicative, educational, and emotional involvement—to promote healthy growth and mitigate cognitive deficits. In summary, children with malignant tumors generally exhibit lower cognitive scores, which can be attributed to their still-developing neural systems and heightened vulnerability to treatment-related neurotoxicity as well as other psychosocial stressors[39–41].

Conclusion

This study found that Cognitive scores of children and adolescents with cancer are at a low level and factors such as disease duration, chemotherapy, disposition, gender, father’s education level, and sleep duration all have significant effect on cognitive impairment. The innovative aspect of our study lies in its comprehensive identification of multifaceted—clinical, demographic, and familial—risk factors within a single cohort, highlighting the particularly underrecognized role of paternal education and sleep quality in this population. These findings carry important clinical implications, suggesting that routine cognitive and sleep assessments should be incorporated into standard oncology care to enable early identification of high-risk patients. Future study should focus on children’s specific psychological and social stressors, as well as their biological causes, and the critical role of psychological variables in prevention and treatment should be properly addressed. Moreover, the results advocate for the development of individualized interventions that target modifiable factors such as sleep, which may help mitigate cognitive decline in clinical practice. Children with malignant tumors should have their sleep quality examined on a regular basis, and intervention measures should be implemented as soon as possible.

Limitation

The main limitations of this study lie in its single-center and cross-sectional design. The data from a single institution may affect the external validity of the results, and the lack of longitudinal follow-up hinders the ability to infer causal relationships between cognitive impairment and its influencing factors.

Abbreviations

ASQ-3

Ages & Stages Questionnaires, Third Edition

CI

Confidence Interval

CRCI

Cancer-Related Cognitive Impairment

FISQ

Full-Scale Intelligence Quotient

OR

Odds Ratio

PTSD

Post-Traumatic Stress Disorder

SCAS-S

Spence Children’s Anxiety Scale – Short Version

SD

Standard Deviation

SDSC

Sleep Disturbance Scale for Children

WISC-IV

Wechsler Intelligence Scale for Children – Fourth Edition

Authors’ contributions

Zefang-Chen: data analysis and manuscript writing/editing. Yali Wang, Tao Liu and Lifang Xu: data collection and manuscript writing. Lin Mo: conceived and designed the study, manuscript editing. Lu Yu and Tao Liu: conceived and designed the study. The manuscript was critically reviewed by all of the authors. All of the authors read and approved the finally manuscript.

Funding

This work was supported in the part by grants from National Natural Science Foundation of China(Great number:72474040)and Chongqing Science and Technology Bureau, China. (Great number: CSTB2023NSCQ-MSX0567, CSTB2024NSC0-MSX1093).

Data availability

Research data are not shared. (The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request).

Declarations

Ethics approval and consent to participate

The study follows the Declaration of Helsinki and approved by Ethics Committee (full name: Institutional Review Board of Children’s Hospital of Chongqing Medical University) (reference number [2023 (year) No.270]) to the Department of Scientific Research, Children’s Hospital of Chongqing Medical University, China. All methods were carried out according to the relevant guideline and regulations. This study was carried out in compliance with the STROBE Statement. All included patients gave their oral and written informed consent. The study was entirely voluntary, and patients will give their consent for this material to appear in academic journals and associated publications.

Consent for publication

All included patients gave their oral and written informed consent. The study was entirely voluntary, and patients will give their consent for this material to appear in academic journals and associated publications.

It is worth mentioning that for the minor children under 16 years of age who participated in this study, the consent of their parents or legal guardians was informed and obtained.

Competing interests

The authors declare no competing interests.