Identifying Palliative Care Needs in Children with Acute Lymphoblastic Leukemia: Validation of the Chinese Pediatric Palliative Screening Scale (C-PaPaS)

Identifying Palliative Care Needs in Children with Acute Lymphoblastic Leukemia: Validation of the Chinese Pediatric Palliative Screening Scale (C-PaPaS) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Identifying Palliative Care Needs in Children with Acute Lymphoblastic Leukemia: Validation of the Chinese Pediatric Palliative Screening Scale (C-PaPaS) Alidannu Nueraili, Junye Jiang, Hongsheng Wang, Xiaohua Zhu, Yi Yu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7808438/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Apr, 2026 Read the published version in BMC Palliative Care → Version 1 posted 12 You are reading this latest preprint version Abstract Background Timely identification of pediatric palliative care (PPC) needs is essential to improving the quality of life for children with life-threatening illnesses. The Pediatric Palliative Screening Scale (PaPaS) has been validated internationally, but it has not yet been evaluated in mainland China, where PPC infrastructure remains limited and fragmented. The aim of this study is to adapt the PaPaS into Chinese and evaluate its diagnostic performance in identifying PPC needs among children with acute lymphoblastic leukemia (ALL) during induction chemotherapy. Methods This retrospective diagnostic accuracy study included children aged 0–18 years newly diagnosed with ALL who initiated induction therapy under the CCCG-ALL-2020 protocol at a tertiary pediatric hospital in China (August 2020–August 2023). The Chinese version of the PaPaS (C-PaPaS) was developed through forward–backward translation and expert review. Scores were retrospectively assigned using electronic medical records. Receiver operating characteristic (ROC) analysis was used to assess diagnostic performance and identify the optimal cutoff. Results Among 153 patients, 28.1% received PPC interventions. Median C-PaPaS scores were significantly higher in the PPC group (23 [IQR 17–25]) than in the non-PPC group (15 [14–19]; P 22, the C-PaPaS demonstrated high sensitivity (93.0%) and moderate specificity (41.8%), with an area under the ROC curve of 0.79 (95% CI: 0.71–0.87). Conclusions The C-PaPaS demonstrated strong sensitivity and moderate discriminative accuracy in identifying PPC needs among children with ALL. It may serve as a useful triage tool to support early palliative integration, especially in settings with limited PPC infrastructure. pediatric palliative care pediatric palliative screening scale diagnostic accuracy sensitivity and specificity Figures Figure 1 Figure 2 Figure 3 Background Pediatric palliative care (PPC) is a holistic, interdisciplinary approach that seeks to alleviate suffering and improve the quality of life for children with life-threatening or life-limiting conditions and their families. 1 PPC addresses physical, emotional, social, and spiritual distress and should be introduced early in the disease course to optimize benefit. Unlike adult palliative care, PPC must accommodate children’s evolving developmental, psychological, and relational needs, as well as family-centered decision-making processes. Globally, nearly 4 million children require palliative care annually. 2 In China alone, over 130,000 deaths occur each year in individuals aged 0–19, with an estimated 69% needing end-of-life care. 3 Yet despite this considerable burden, PPC remains underdeveloped. Service availability is limited, referral practices are inconsistent, and PPC delivery is often delayed until the terminal phase. 4 One contributing factor is the lack of validated, structured screening tools to assist clinicians in timely identification of PPC needs. In their absence, decisions are frequently made based on subjective clinical impressions, increasing the risk of unmet needs, unrelieved suffering, and reactive rather than anticipatory care. The Pediatric Palliative Screening Scale (PaPaS), developed by Bergstraesser et al. in 2013, is a clinician-facing tool designed to guide PPC referral based on disease trajectory, symptom burden, psychosocial distress, and clinician concern. 5 It has been tested in diverse settings including Singapore 6 , South Korea 7 , India 8 , and Peru 9 , showing feasibility and diagnostic utility in both oncologic and non-oncologic populations. However, it has not yet been translated or evaluated in mainland China. Nor has it been assessed specifically in children with hematologic malignancies, where the acute intensity and symptom complexity may necessitate tailored application. Acute lymphoblastic leukemia (ALL), the most common pediatric cancer in China, is emblematic of this challenge. Children with ALL, particularly during induction chemotherapy, often experience substantial physical and psychological symptom burdens, e.g., mucositis, gastrointestinal distress, fatigue, and emotional turmoil. 10 , 11 Treatment toxicities, prolonged hospitalizations, and disruption to daily routines impose a significant toll on both the patient and family. 12 Yet, PPC during this high-need phase remains inconsistently integrated, often reserved for late-stage care or crisis management. 13 To address this gap, we translated the PaPaS into Chinese and conducted a diagnostic accuracy study in a cohort of children with ALL during induction therapy. Our objectives were to evaluate the scale’s sensitivity, specificity, and optimal diagnostic cutoff within healthcare systems where PPC infrastructure is still emerging. Methods Study Design We conducted a retrospective diagnostic accuracy study to evaluate the performance of the Chinese version of the Pediatric Palliative Screening Scale (C-PaPaS) in identifying palliative care (PPC) needs among children with acute lymphoblastic leukemia (ALL). The study adhered to the 2015 Standards for Reporting Diagnostic Accuracy Studies (STARD) guidelines to ensure methodological transparency and scientific rigor. The study was approved by the Ethics Committee of the Children's Hospital of Fudan University (registration number 2021/512). Participants Children aged 0–18 years who were newly diagnosed with ALL and initiated treatment under the CCCG-ALL-2020 chemotherapy protocol at the Children’s Hospital of Fudan University between August 1, 2020, and August 31, 2023, were screened for eligibility. The CCCG-ALL-2020 protocol is registered in the Chinese Clinical Trial Registry (ChiCTR2000035264). Patients were enrolled at the start of induction chemotherapy. Exclusion criteria included discontinuation of treatment during induction or loss to follow-up. Data Collection and Management Demographic and clinical variables were extracted from the CCCG-ALL-2020 registry and the institutional electronic medical record (EMR) system. Extracted variables included age at diagnosis, sex, ALL subtype, initial white blood cell count, blast percentages in peripheral blood and bone marrow, central nervous system (CNS) or testicular involvement, initial and final risk stratification, minimal residual disease (MRD) levels on days 19 and 46, and molecular genetic markers (e.g., ETV6-RUNX1, TCF3-PBX1, BCR-ABL1, KMT2A rearrangement). Additionally, documentation of supportive and psychosocial care services during induction therapy was systematically collected, including nutritional consultations, psychological support, anesthesiology referrals for pain management, and administration of pharmacologic analgesia. Data extraction was performed independently by a trained research assistant using a pre-defined data abstraction protocol. Data quality was verified through double entry and reviewed by the study investigators for accuracy and completeness. Reference Standard for Palliative Care Need In alignment with international conceptualizations of pediatric palliative care as a multidimensional and interdisciplinary approach to alleviating suffering, we operationalized PPC engagement using a pragmatic, service-based reference standard. patients were classified as having received PPC if they engaged with any of the following documented services during induction therapy: consultation with supportive care disciplines, including psychology, nutrition, rehabilitation, or anesthesiology (for pain management); attendance at the hospital’s multidisciplinary palliative care (MDT) outpatient clinic; administration of pharmacologic pain management (e.g., tramadol or stronger opioids); Referral to medical social work or family support services.This composite standard was informed by international PPC principles and tailored to reflect the integrated, non-billable nature of palliative care delivery in China, where PPC is frequently embedded within general supportive services rather than offered as a stand-alone clinical domain. Chinese Pediatric Palliative Screening Scale (C-PaPaS) Development and Scoring The C-PaPaS was developed through a structured, multi-step linguistic and clinical adaptation process to ensure semantic, cultural, and functional equivalence with the original Pediatric Palliative Screening Scale (PaPaS), which includes 11 items across five domains: disease trajectory, symptom burden, psychological/family distress, treatment burden, and clinician judgment. With permission from the original and revised scale developers, the PaPaS was translated into Chinese using a standard forward–backward translation protocol. The initial translation was independently performed by bilingual professionals, followed by back-translation by a separate translator blinded to the original content. Discrepancies were reconciled through discussion among the core research team.The preliminary version was then reviewed by an expert panel comprising a pediatric palliative care clinician, a pediatric hemato-oncologist, and a medical language specialist. Adaptations were made to align terminology with Chinese clinical practices and cultural context. The finalized Chinese version of the scale (C-PaPaS) retained the original domain structure, and the English version of the scale is provided in Supplementary File 2. C-PaPaS scoring was conducted retrospectively and independently by trained reviewers using electronic medical records (EMR) and follow-up documentation. Items related to treatment complexity, unplanned hospitalizations, and symptom control were assessed based on medical records. Items related to psychological burden, family distress, or patient/parent preferences were evaluated based on follow-up interactions, multidisciplinary notes, or caregiver communication logs. Scores reflected conditions during the induction phase and were assigned prior to outcome classification to reduce potential bias. Statistical Analysis Descriptive statistics were used to summarize patient characteristics. Continuous variables are reported as medians with interquartile ranges (IQRs); categorical variables as frequencies and percentages. Normality was assessed using histograms and the Kolmogorov-Smirnov test. Between-group comparisons were conducted using Student’s t-test or the Mann-Whitney U test for continuous variables, and the chi-square test for categorical variables. Diagnostic performance metrics for the C-PaPaS, i.e., sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy—were calculated using the composite reference standard. The area under the receiver operating characteristic curve (AUC) was computed to assess overall discriminative performance. The Youden Index was used to determine the optimal diagnostic cutoff score. All analyses were performed using IBM SPSS Statistics version 29.0 (IBM Corp., Armonk, NY, USA). Results Participants Of the 165 potential participants newly diagnosed with acute lymphoblastic leukemia (ALL) screened for eligibility, 12 were excluded due to loss to follow-up or inability to establish contact. The final analytic sample comprised 153 patients. Based on documented engagement with one or more palliative or supportive services, 28.1% (n = 43) were classified into the palliative care (PPC) group, while 71.9% (n = 110) constituted the non-PPC group (see Supplementary File 1). In the PPC group, 55.8% (n = 24) were male, and the median age at diagnosis was 97 months (IQR: 50–140.5). In the non-PPC group, 55.5% (n = 61) were male, with a median age of 57.5 months (IQR: 38–92). Compared to their counterparts, children in the PPC group were significantly more likely to be aged ≥ 10 years and to fall into a non-low-risk category at initial diagnosis (P < 0.05). No other demographic or clinical characteristics differed significantly between groups (Table 1 ). Table 1 Patients characteristics PPC non-PPC n % n % \(\:{\varvec{\chi\:}}^{2}\) /Fisher P value Gender 0.002 0.968 male 24 55.8 61 55.5 female 19 44.2 49 45.5 Age at diagnosis 2.227 < 0.01 < 10 years 28 65.1 98 89.1 ≥ 10 years 15 34.9 12 10.9 ALL type 2.165 0.151 B-ALL 36 83.7 101 91.8 T-ALL 7 16.3 9 8.2 WBC count 2.12 0.145 < 50×10⁹/L 32 74.4 93 84.5 ≧ 50×10⁹/L 11 25.6 17 15.5 PB blast cell 2.154 0.341 ≧ 30% 26 60.5 53 48.2 < 30% 11 20.4 41 37.3 no 6 14 16 14.5 BM blast cell 0.706 0.401 ≧ 95% 22 51.2 48 43.6 < 95% 21 48.8 62 56.4 CNS involvement 2.594 0.255 no 41 95.3 107 97.3 yes 2 4.7 3 0.9 Testicular involvement 0.484 yes 1 1 no 42 109 Fusion gene 2.791 0.095 positive 11 25.6 44 40 negative 32 74.4 66 60 Day19 MRD 0.299 0.632 < 0.01% 22 51.2 61 55.5 ≧ 0.01% 21 48.8 49 45.5 Day46 MRD 0.74 < 0.01% 39 90.7 102 92.7 ≧ 0.01% 4 9.3 8 7.3 Initial risk 6.343 0.012 low risk 19 44.2 73 66.4 non-low risk 24 55.8 37 33.6 Final risk 3.338 0.068 low risk 16 37.2 59 53.6 non-low risk 27 62.8 51 46.4 The most frequently utilized palliative services in the PPC group included nutritional, psychological, rehabilitation, and anesthesiology consultations, as well as pharmacologic pain management (e.g., tramadol). Nutrition support represented the most common service. C-PaPaS Scores All patients were retrospectively assessed using the Chinese version of the Pediatric Palliative Screening Scale (C-PaPaS). The overall median score was 17 (IQR: 14–21). Children in the PPC group had significantly higher scores (median: 23, IQR: 17–25) compared to those in the non-PPC group (median: 15, IQR: 14–19; P < 0.001) (Fig. 1 ). A, the boxplot shows the C-PaPaS score of the all patients. B, the boxplot shows the difference in C-PaPaS scores between PPC group and non-PPC group. To further characterize score distribution, patients were stratified into three score bands: 10–15, 15–25, and 25–35. The proportion of patients in each band differed significantly between PPC and non-PPC groups (P < 0.01), with higher C-PaPaS scores associated with increased likelihood of receiving PPC (Fig. 2 ). A, The histogram shows the distribution of all patients according to the C-PaPaS scores. B, The histogram shows the difference in the distribution of two groups according to the C-PaPaS scores. Diagnostic Accuracy A 2×2 diagnostic contingency table (Table 2 ) was constructed using the C-PaPaS as the index test and documented PPC engagement as the reference standard. Corresponding diagnostic performance metrics, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). (Table 3 ) Table 2 Four-quadrant table PaPaS Scoring Diagnostic standard Total PPC non-PPC PPC 40(a) 64(b) 104(a + b) non-PPC 3(c) 46(d) 49(c + d) Total 43(a + c) 110(b + d) 153(a + b + c + d) Table 3 Diagnostic Performance Indices Using the PaPaS Scale for Diagnosing PC needs Indices PaPaS Scale Cutoff ≥ 15 Sensitivity, %, (95% CI) 93.0 (85.0,100.0) Specificity, %, (95% CI) 41.8 (32.5,51.2) NPV, %, (95% CI) 93.9 (86.9,100.0) PPV, %, (95% CI) 38.5 (29.0,48.0) AUROC, (95% CI) 0.79 (0.71–0.87) Receiver operating characteristic (ROC) curve analysis demonstrated good discriminative performance, with an area under the curve (AUC) of 0.79 (95% CI: 0.71–0.87) (Fig. 3 ). The optimal diagnostic cutoff score, determined via the Youden Index, was > 22. At this threshold, the C-PaPaS demonstrated a specificity of 92.7% (95% CI: 0.71–0.87), and a sensitivity of 51.2%, indicating strong rule-in capacity for PPC need, though with limited sensitivity to detect all eligible cases. Receiver operating characteristic (ROC) curve for the PaPaS scale (AUROC = 0.79) when compared with the diagnosis standard. Discussion This study represents the first validation of the Pediatric Palliative Screening Scale (PaPaS) in mainland China, showing that the Chinese version (C-PaPaS) can reliably identify palliative care needs among children with acute lymphoblastic leukemia (ALL) during the induction chemotherapy phase. The C-PaPaS demonstrated high sensitivity (93.0%) and moderate discriminative capacity (AUC = 0.79), aligning with growing evidence on the benefit of early PPC integration in pediatric oncology settings. 14 This finding supports C-PaPaS’s clinical utility as a screening tool for identifying pediatric palliative care (PPC) needs during early, high-burden phases of treatment. Although specificity was relatively low (41.8%) compared to the optimal values (> 90%) reported in prior validations like those from Singapore, 6 this difference is likely attributable to distinct healthcare contexts and outcome definitions. The earlier studies employed long-term PPC enrollment as the endpoint, while our pragmatic reference standard focused on service engagement during a defined high-need window. In regions with nascent PPC systems like China, where structural support is evolving, documentation inconsistencies and lower referral thresholds can increase false positives. Nevertheless, high sensitivity is preferable in resource-limited settings, ensuring early triage and minimizing missed opportunities for symptom relief and supportive interventions, as emphasized in recent systematic reviews of PPC implementation in low- and middle-income countries. 15 Of note, high sensitivity may be an asset rather than a limitation in resource-constrained environments or healthcare systems with emerging pediatric palliative care infrastructure. In such contexts, a high-sensitivity tool like the C-PaPaS can serve as an efficient triage mechanism to ensure that no child with significant palliative needs is overlooked. This trade-off favors early over-identification to prompt further assessment—a justifiable approach when access to specialist palliative services is limited or variably documented. Recent systematic reviews have emphasized the importance of inclusive screening approaches in low- and middle-income countries (LMICs), where early identification may activate existing but underutilized supportive resources and mitigate symptom escalation 15 . Future tiered models may therefore combine initial screening via the C-PaPaS with confirmatory assessments using clinical interviews, caregiver-reported outcomes, or validated quality-of-life instruments to improve specificity and refine referral pathways. 16 The optimal cutoff score identified in this study (> 22) is higher than those reported in prior validations, such as in Singapore and South Korea. 6 This may reflect the distinct symptom burden associated with acute lymphoblastic leukemia (ALL) induction therapy, which commonly includes mucositis, gastrointestinal complications, pain, and emotional distress. Such symptoms—compounded by prolonged hospitalization and treatment intensity—have been shown to adversely affect both quality of life and adherence. 12 The C-PaPaS effectively captured this multidimensional burden, highlighting its clinical relevance in acute-phase PPC screening. However, given the study’s single-center design and reliance on retrospective documentation, caution is warranted in applying the cutoff score across other institutions or disease contexts without further validation. Subgroup analysis revealed that adolescents (aged ≥ 10 years) and children classified as high-risk at diagnosis were more likely to receive palliative care services. This pattern holds important clinical implications: older children experience unique developmental vulnerabilities—including increased illness awareness, body image concerns, academic disruption, and existential anxiety—on top of intensified treatment burdens. Recent evidence underscores these vulnerabilities. Aretrospective study of adolescent and young adult cancer patients (aged 16–39) showed that psychological factors such as anxiety, body image distress, and existential fears are prevalent and inadequately addressed during standard oncology care. 17 This reinforces the need for age-specific supportive interventions. The C‑PaPaS appears well-suited to identify this at-risk group by capturing a multidimensional burden across clinical, psychosocial, and familial domains. By offering standardized, proactive screening, it supports the implementation of age- and risk-adapted palliative strategies in intensive treatment settings. Such strategies can help close service gaps and ensure timely symptom management, emotional support, and psychosocial intervention for older children during induction therapy, which is an essential step toward equitable, developmentally appropriate PPC integration. This study offers a practical model for adapting and implementing pediatric palliative care,screening tools in settings where PPC systems are still emerging. While China is not an LMIC, its pediatric oncology PPC infrastructure remains underdeveloped, with limited standardization, cultural barriers, and variable referral practices. 17 By demonstrating the cultural adaptation and validation of the PaPaS in an acute pediatric oncology context, our findings provide transferable insights for health systems facing similar challenges. The use of a high-sensitivity tool like the C-PaPaS for early triage—paired with follow-up assessment through clinical or caregiver-reported measures—aligns with global early-phase PPC integration strategies. This approach, supported by pragmatic service-based reference standards, may inform scalable PPC implementation across diverse care settings. 18 This study has several limitations. It was conducted at a single tertiary pediatric oncology center with a moderate sample size, potentially limiting generalizability across institutions and health systems. The relatively homogeneous cohort restricted exploration of contextual factors such as socioeconomic variation or regional disparities that may influence palliative care access. The retrospective design relied on routine clinical documentation, which may have introduced inconsistencies in data completeness and accuracy, affecting both C-PaPaS scoring and classification of palliative care engagement. Additionally, in China’s early-stage PPC landscape, where services are embedded in general supportive care and lack formal referral pathways, our use of a pragmatic, service-based reference standard may have underestimated unmet needs or misclassified borderline cases. Nevertheless, it holds the potential of offering a feasible method for real-world classification when prospective adjudication is not available. Given that the original PaPaS has been validated in high-income countries, this study contributes important evidence supporting its cultural adaptation and real-world application in a health system where PPC is still emerging. To further strengthen the utility of the C-PaPaS, future research should include larger, multicenter, and prospectively designed studies that incorporate diverse demographic and healthcare settings. Cross-system validation, especially in mature PPC environments, will help benchmark diagnostic performance and guide international adaptation. Refinements to the scoring algorithm, e.g., differential weighting or machine learning–based optimization may improve diagnostic precision. Integrating the C-PaPaS into a tiered screening model, followed by structured clinical interviews or caregiver-reported outcomes, could enhance specificity while maintaining its triage value. Such a strategy aligns with global implementation science frameworks and may accelerate PPC integration in pediatric oncology settings with varying resource levels. Conclusions This study demonstrates that the C-PaPaS is a feasible and sensitive tool for identifying palliative care needs in children with acute lymphoblastic leukemia during induction therapy. The scale showed good diagnostic performance, particularly in detecting high-need cases in a setting where PPC services are still developing. While specificity was limited, the C-PaPaS offers a practical approach to support early screening and referral in pediatric oncology. List of abbreviations PPC Pediatric palliative care PaPaS Pediatric palliative care screening scale ALL Acute lymphoblastic leukemia CCCG-ALL-2020 Chinese Children’s Cancer Group Acute Lymphoblastic Leukemia 2020 protocol C-PaPaS Chinese version of the pediatric palliative care screening scale ROC Receiver Operating Characteristic STARD Standards for Reporting of Diagnostic Accuracy Studies EMR Electronic Medical Record CNS Central Nervous System MRD Minimal Residual Disease MDT Multidisciplinary Team IQR Interquartile Range PPV Positive Predictive Value NPV Negative Predictive Value AUC Area Under the Curve LMICs Low- and Middle-Income Countries Declarations Acknowledgements We would like to thank the patients and their families who participated in this study, as well as the multidisciplinary team at the Children’s Hospital of Fudan University for their support. Funding The work was supported by the National Key Research and Development Program of China (No. 2023YFC2706301), National Key Research and Development Program of China (No. 2022YFC2705003), National Natural Science Foundation of China (82141125), Science and Technology Commission of Shanghai Municipality (21Y31900302). China Medical Board Open Competition Grant (#21-427) Availability of data and materials The datasets generated and/or analyzed during the current study are available upon the request from the corresponding coauthor Xiaowen Zhai. Authors' contributions Lei Cheng obtained permission from the original author to use and translate the scale. Alidannu nueraili, Junye Jiang, Hongsheng Wang, Lei Cheng, Xiaowen zhai Completed the translation, linguistic adaptation of the scale, contributed to the analysis plan, and interpretation of findings. Alidannu Nueraili conducted the data analysis,and drafted the manuscript. Junye jiang, Hongsheng Wang, Xiaohua Zhu, Yi Yu, Ping Cao, Yang FU, Jun Li, Ling Yu, Lei Cheng, Xiaowen Zhai reviewed the manuscript, revised it critically for important intellectual content, and edited it to make it read well in English. Xiaowen Zhai was responsible for the study design, supervised the study, led the data collection, revise the manuscript, and approval of the final draft. Alidannu Nueraili, Junye Jiang, and Hongsheng Wang contributed equally to this work as co-first authors. Ethics approval and consent to participate The present study has been reviewed and approved by the Ethics Committee of the Children's Hospital of Fudan University (registration number 2021/512). Informed consent to participate was obtained from all participants (or their legal guardians). The study was conducted in accordance with the Declaration of Helsinki. Competing interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. References Boucher NA, Johnson KS, LeBlanc TW. Acute Leukemia Patients' Needs: Qualitative Findings and Opportunities for Early Palliative Care. J Pain Symptom Manage. 2018;55(2):433–9. Connor SR, Downing J, Marston J. Estimating the Global Need for Palliative Care for Children: A Cross-sectional Analysis. J Pain Symptom Manage. 2017;53(2):171–7. Cai S, Guo Q, Wang X, et al. Development levels of pediatric palliative care teams and the extent of palliative care understanding and implementation among pediatric oncologists in China. Pediatr Investig. 2021;5(4):265–70. Yu L, Wu M, Cheng L et al. Chinese Providers' Perspectives on Early Integration of Palliative Care in Pediatric Oncology: A Mixed-Methods Study. Cancer Nurs 2024. Bergstraesser E, Hain RD, Pereira JL. The development of an instrument that can identify children with palliative care needs: the Paediatric Palliative Screening Scale (PaPaS Scale): a qualitative study approach. BMC Palliat Care. 2013;12(1):20. Chong PH, Soo J, Yeo ZZ, Ang RQ, Ting C. Who needs and continues to need paediatric palliative care? An evaluation of utility and feasibility of the Paediatric Palliative Screening scale (PaPaS). BMC Palliat Care. 2020;19(1):18. Song IG, Kwon SY, Chang YJ, et al. Paediatric palliative screening scale as a useful tool for clinicians' assessment of palliative care needs of pediatric patients: a retrospective cohort study. BMC Palliat Care. 2021;20(1):73. Andriastuti M, Halim PG, Kusrini E, Bangun M. Correlation of Pediatric Palliative Screening Scale and Quality of Life in Pediatric Cancer Patients. Indian J Palliat Care. 2020;26(3):338–41. Ugaz C, Ortiz I, Soto G, Morales R, Vasquez L. Pediatric Palliative Screening Scale in pediatric cancer patients: A qualitative study approach. Pediatr Blood Cancer. 2021;68(12):e29249. Ni X, Li Z, Li X, et al. Socioeconomic inequalities in cancer incidence and access to health services among children and adolescents in China: a cross-sectional study. Lancet. 2022;400(10357):1020–32. Zhou YL, An JL, Tian L. Epidemiological analysis of childhood cancer in China. Chin J Contemp Pediatr. 2015;17(7):649–54. Li R, Shen X, Yang Q, et al. Stability of Symptom Clusters in Children With Acute Lymphoblastic Leukemia Undergoing Chemotherapy. Cancer Nurs. 2024;47(5):E348–59. Ferraz A, Santos M, Pereira MG. Parental distress in childhood acute lymphoblastic leukemia: A systematic review of the literature. J Fam Psychol. 2024;38(1):149–60. Lacerda A, Martínez MA, Dumont B et al. Embracing paediatric palliative care in paediatric oncology from diagnosis onwards. Pediatr Blood Cancer 2023:e30561. Kenneson SA, Hughes-Visentin A, Wrigley J, et al. Pediatric Palliative Care Program Implementation in LMICs: A Systematic Review using SWOT Analysis. J Pain Symptom Manage. 2023;66(4):338–e350311. Taub S, Macauley R. Early and often: Promoting early integration of pediatric palliative care for seriously ill children with cancer. Curr Probl Cancer. 2023;47(5):101023. Watanabe H, Watanabe A, Fujikawa K, et al. Characteristics of adolescent and young adult patients with cancer receiving home-based palliative care: A retrospective study at a single center. Support Care Cancer. 2024;32(11):748. Maniago JD, Ngaya-An FV. Implementation Science of Paediatric Palliative Care in Lower-Middle-Income Countries in Southeast Asia: An Integrative Review. Indian J Palliat Care. 2022;28(1):80–7. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1.jpg Supplementaryfile2.docx Cite Share Download PDF Status: Published Journal Publication published 17 Apr, 2026 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 26 Jan, 2026 Reviews received at journal 24 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviews received at journal 19 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviewers agreed at journal 05 Jan, 2026 Reviewers invited by journal 14 Nov, 2025 Editor assigned by journal 14 Nov, 2025 Editor invited by journal 30 Oct, 2025 Submission checks completed at journal 30 Oct, 2025 First submitted to journal 30 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7808438","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":549676242,"identity":"e69fabbe-666a-450b-bfbd-711a42895820","order_by":0,"name":"Alidannu Nueraili","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Alidannu","middleName":"","lastName":"Nueraili","suffix":""},{"id":549676243,"identity":"0dc59ee3-13a9-4a1c-9279-02afb37d319f","order_by":1,"name":"Junye Jiang","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Junye","middleName":"","lastName":"Jiang","suffix":""},{"id":549676244,"identity":"4071315f-0ad1-4b13-80bb-9c696337e199","order_by":2,"name":"Hongsheng Wang","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Hongsheng","middleName":"","lastName":"Wang","suffix":""},{"id":549676245,"identity":"3c2bcb18-6591-4010-af84-2d6967ad30e5","order_by":3,"name":"Xiaohua Zhu","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Xiaohua","middleName":"","lastName":"Zhu","suffix":""},{"id":549676246,"identity":"ddc999d2-adad-461f-844b-35088bee6ac8","order_by":4,"name":"Yi Yu","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Yu","suffix":""},{"id":549676249,"identity":"5f4e2677-420a-47fe-a276-af037f38ba64","order_by":5,"name":"Ping Cao","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Ping","middleName":"","lastName":"Cao","suffix":""},{"id":549676251,"identity":"60a19f86-8bfb-41f3-8dc4-ff8af5cd4ff7","order_by":6,"name":"Yang Fu","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Fu","suffix":""},{"id":549676253,"identity":"eda90c28-bfa9-456c-947e-99bf48ee96a8","order_by":7,"name":"Jun Li","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Li","suffix":""},{"id":549676254,"identity":"af8ac7af-223f-4d04-9b48-8e68e405e164","order_by":8,"name":"Ling Yu","email":"","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Ling","middleName":"","lastName":"Yu","suffix":""},{"id":549676255,"identity":"7f79fb8b-ffbe-4a54-8e97-9708274f2e10","order_by":9,"name":"Lei Cheng","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Cheng","suffix":""},{"id":549676256,"identity":"b77f4e3d-a57a-4db3-b333-d0a163eefea8","order_by":10,"name":"Xiaowen Zhai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYDACCQaGAwwGMHaFhJw8iVrOWBgbNhChBcFmbKtIBJqAH8jPbn54mKfATs7geO/B27zzJBIYG5gfPrqBRwvjnGMGB2cYJBsbnDmXbM27TSKPnYHN2DgHjxZmiQSDAx8MmBO33cgxkwZqKWZs4GGTxqeFTSL9w4EEg/rEbfffALXMkUhsOEBAC49EDsiWw0BbeIBaGojQIiGRUwD0y3Fj+zM5xpZzjkkYGzYT8Iv8jPTNn3n+VMtJtp8xvPGmpk5Onr354WN8WlAAEw+IZCZWOQgw/iBF9SgYBaNgFIwYAADeO0mxKvYthQAAAABJRU5ErkJggg==","orcid":"","institution":"Children’s Hospital of Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Xiaowen","middleName":"","lastName":"Zhai","suffix":""}],"badges":[],"createdAt":"2025-10-08 13:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7808438/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7808438/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-026-02080-6","type":"published","date":"2026-04-17T15:58:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":96915952,"identity":"b049ef1a-37fc-4c37-93d5-20d4e13cf550","added_by":"auto","created_at":"2025-11-27 14:07:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":192299,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/3590bab03d62bb75c652b30f.docx"},{"id":96792291,"identity":"32816b92-0daf-47c2-a9ea-bbd877942ddd","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12056,"visible":true,"origin":"","legend":"","description":"","filename":"228762d453aa446e9002ba9ee63210f4.json","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/d41f38ad4ad318b3d3811ba5.json"},{"id":96792295,"identity":"ae1d2e77-1310-45ab-bc0e-3b452562a5a4","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":542467,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/01a8d016161a4fdf3c210795.jpg"},{"id":96792297,"identity":"7756f8b8-9e43-45dd-b2b4-a5176ec15696","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":20797,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/a4e9e3fff0b678995a4fcc7b.docx"},{"id":96792303,"identity":"0c9cdbd7-d0dd-49a9-9661-4cedbb59c787","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89128,"visible":true,"origin":"","legend":"","description":"","filename":"228762d453aa446e9002ba9ee63210f41enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/a6ef6aba8a7c5c0332a760b9.xml"},{"id":96792302,"identity":"fa9dbeb4-978a-4868-a335-d976192e0002","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14166,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/046777c54f809236a2f0cede.png"},{"id":96792300,"identity":"459a4098-956c-4c51-aba7-7fee043aa647","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23393,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/b655562576ea8eaaa009f695.png"},{"id":96792301,"identity":"799d150d-9cf9-435f-a6a0-33403402f32d","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":11713,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/62b58d8ebf86bd4d4f8e6b13.png"},{"id":96916429,"identity":"a8b42a10-23bd-487b-8353-3c38cc92947a","added_by":"auto","created_at":"2025-11-27 14:08:33","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85843,"visible":true,"origin":"","legend":"","description":"","filename":"228762d453aa446e9002ba9ee63210f41structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/454573f4a1d452497bd45c0b.xml"},{"id":96792304,"identity":"8ffa6cfc-b275-4f49-a87a-1ec1fc962e3c","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96736,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/def3cac376f910bc81457a03.html"},{"id":96917061,"identity":"509102a3-21c4-44c3-a22b-b0e31d12cef7","added_by":"auto","created_at":"2025-11-27 14:09:13","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39577,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePaPaS score for all patients and two groups of patients.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA, the boxplot shows the C-PaPaS score of the all patients. B, the boxplot shows the difference in C-PaPaS scores between PPC group and non-PPC group.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/6e514924c04494071d8d212b.jpeg"},{"id":96792293,"identity":"17342795-a683-42e3-a08b-324150301f49","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":42734,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of PaPaS score\u003c/p\u003e\n\u003cp\u003eA, The histogram shows the distribution of all patients according to the C-PaPaS scores. B, The histogram shows the difference in the distribution of two groups according to the C-PaPaS scores.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/9fda56dcefceb1cff4fe9712.jpeg"},{"id":96917077,"identity":"18ba65a4-665f-47e5-9317-1c739008a89d","added_by":"auto","created_at":"2025-11-27 14:09:14","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":22590,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic\u003c/p\u003e\n\u003cp\u003eReceiver operating characteristic (ROC) curve for the PaPaS scale (AUROC = 0.79) when compared with the diagnosis standard.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/5e62b49d9ac6e38aefb5074e.jpeg"},{"id":107350928,"identity":"97b59f0b-5f2e-421d-883f-d3c8287fc2c1","added_by":"auto","created_at":"2026-04-20 16:07:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":637217,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/94e95b4e-53fd-44d2-8305-f9fbaca3247f.pdf"},{"id":96792296,"identity":"48a152ec-474e-4042-908c-e586e6a20420","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"jpg","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":542467,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/bd3f1ff5eaff6d8a5e204ffa.jpg"},{"id":96792294,"identity":"b0b3d63f-8684-4d8d-b0b5-7c2d07c35ea1","added_by":"auto","created_at":"2025-11-26 07:02:01","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20797,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7808438/v1/4c0e9e6b5fc5b716505c6fdb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Identifying Palliative Care Needs in Children with Acute Lymphoblastic Leukemia: Validation of the Chinese Pediatric Palliative Screening Scale (C-PaPaS)","fulltext":[{"header":"Background","content":"\u003cp\u003ePediatric palliative care (PPC) is a holistic, interdisciplinary approach that seeks to alleviate suffering and improve the quality of life for children with life-threatening or life-limiting conditions and their families. \u003csup\u003e1\u003c/sup\u003e PPC addresses physical, emotional, social, and spiritual distress and should be introduced early in the disease course to optimize benefit. Unlike adult palliative care, PPC must accommodate children\u0026rsquo;s evolving developmental, psychological, and relational needs, as well as family-centered decision-making processes.\u003c/p\u003e\u003cp\u003eGlobally, nearly 4\u0026nbsp;million children require palliative care annually.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In China alone, over 130,000 deaths occur each year in individuals aged 0\u0026ndash;19, with an estimated 69% needing end-of-life care. \u003csup\u003e3\u003c/sup\u003e Yet despite this considerable burden, PPC remains underdeveloped. Service availability is limited, referral practices are inconsistent, and PPC delivery is often delayed until the terminal phase. \u003csup\u003e4\u003c/sup\u003e One contributing factor is the lack of validated, structured screening tools to assist clinicians in timely identification of PPC needs. In their absence, decisions are frequently made based on subjective clinical impressions, increasing the risk of unmet needs, unrelieved suffering, and reactive rather than anticipatory care.\u003c/p\u003e\u003cp\u003eThe Pediatric Palliative Screening Scale (PaPaS), developed by Bergstraesser et al. in 2013, is a clinician-facing tool designed to guide PPC referral based on disease trajectory, symptom burden, psychosocial distress, and clinician concern. \u003csup\u003e5\u003c/sup\u003e It has been tested in diverse settings including Singapore\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, South Korea\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, India\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, and Peru\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, showing feasibility and diagnostic utility in both oncologic and non-oncologic populations. However, it has not yet been translated or evaluated in mainland China. Nor has it been assessed specifically in children with hematologic malignancies, where the acute intensity and symptom complexity may necessitate tailored application.\u003c/p\u003e\u003cp\u003eAcute lymphoblastic leukemia (ALL), the most common pediatric cancer in China, is emblematic of this challenge. Children with ALL, particularly during induction chemotherapy, often experience substantial physical and psychological symptom burdens, e.g., mucositis, gastrointestinal distress, fatigue, and emotional turmoil.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003eTreatment toxicities, prolonged hospitalizations, and disruption to daily routines impose a significant toll on both the patient and family. \u003csup\u003e12\u003c/sup\u003eYet, PPC during this high-need phase remains inconsistently integrated, often reserved for late-stage care or crisis management. \u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTo address this gap, we translated the PaPaS into Chinese and conducted a diagnostic accuracy study in a cohort of children with ALL during induction therapy. Our objectives were to evaluate the scale\u0026rsquo;s sensitivity, specificity, and optimal diagnostic cutoff within healthcare systems where PPC infrastructure is still emerging.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eWe conducted a retrospective diagnostic accuracy study to evaluate the performance of the Chinese version of the Pediatric Palliative Screening Scale (C-PaPaS) in identifying palliative care (PPC) needs among children with acute lymphoblastic leukemia (ALL). The study adhered to the 2015 Standards for Reporting Diagnostic Accuracy Studies (STARD) guidelines to ensure methodological transparency and scientific rigor. The study was approved by the Ethics Committee of the Children's Hospital of Fudan University (registration number 2021/512).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eChildren aged 0\u0026ndash;18 years who were newly diagnosed with ALL and initiated treatment under the CCCG-ALL-2020 chemotherapy protocol at the Children\u0026rsquo;s Hospital of Fudan University between August 1, 2020, and August 31, 2023, were screened for eligibility. The CCCG-ALL-2020 protocol is registered in the Chinese Clinical Trial Registry (ChiCTR2000035264). Patients were enrolled at the start of induction chemotherapy. Exclusion criteria included discontinuation of treatment during induction or loss to follow-up.\u003c/p\u003e\n\u003ch3\u003eData Collection and Management\u003c/h3\u003e\n\u003cp\u003eDemographic and clinical variables were extracted from the CCCG-ALL-2020 registry and the institutional electronic medical record (EMR) system. Extracted variables included age at diagnosis, sex, ALL subtype, initial white blood cell count, blast percentages in peripheral blood and bone marrow, central nervous system (CNS) or testicular involvement, initial and final risk stratification, minimal residual disease (MRD) levels on days 19 and 46, and molecular genetic markers (e.g., ETV6-RUNX1, TCF3-PBX1, BCR-ABL1, KMT2A rearrangement). Additionally, documentation of supportive and psychosocial care services during induction therapy was systematically collected, including nutritional consultations, psychological support, anesthesiology referrals for pain management, and administration of pharmacologic analgesia. Data extraction was performed independently by a trained research assistant using a pre-defined data abstraction protocol. Data quality was verified through double entry and reviewed by the study investigators for accuracy and completeness.\u003c/p\u003e\u003cp\u003e\u003cb\u003eReference Standard for Palliative Care Need\u003c/b\u003e\u003c/p\u003e\u003cp\u003e In alignment with international conceptualizations of pediatric palliative care as a multidimensional and interdisciplinary approach to alleviating suffering, we operationalized PPC engagement using a pragmatic, service-based reference standard. patients were classified as having received PPC if they engaged with any of the following documented services during induction therapy: consultation with supportive care disciplines, including psychology, nutrition, rehabilitation, or anesthesiology (for pain management); attendance at the hospital\u0026rsquo;s multidisciplinary palliative care (MDT) outpatient clinic; administration of pharmacologic pain management (e.g., tramadol or stronger opioids); Referral to medical social work or family support services.This composite standard was informed by international PPC principles and tailored to reflect the integrated, non-billable nature of palliative care delivery in China, where PPC is frequently embedded within general supportive services rather than offered as a stand-alone clinical domain.\u003c/p\u003e\n\u003ch3\u003eChinese Pediatric Palliative Screening Scale (C-PaPaS) Development and Scoring\u003c/h3\u003e\n\u003cp\u003eThe C-PaPaS was developed through a structured, multi-step linguistic and clinical adaptation process to ensure semantic, cultural, and functional equivalence with the original Pediatric Palliative Screening Scale (PaPaS), which includes 11 items across five domains: disease trajectory, symptom burden, psychological/family distress, treatment burden, and clinician judgment. With permission from the original and revised scale developers, the PaPaS was translated into Chinese using a standard forward\u0026ndash;backward translation protocol. The initial translation was independently performed by bilingual professionals, followed by back-translation by a separate translator blinded to the original content. Discrepancies were reconciled through discussion among the core research team.The preliminary version was then reviewed by an expert panel comprising a pediatric palliative care clinician, a pediatric hemato-oncologist, and a medical language specialist. Adaptations were made to align terminology with Chinese clinical practices and cultural context. The finalized Chinese version of the scale (C-PaPaS) retained the original domain structure, and the English version of the scale is provided in Supplementary File 2.\u003c/p\u003e\u003cp\u003e C-PaPaS scoring was conducted retrospectively and independently by trained reviewers using electronic medical records (EMR) and follow-up documentation. Items related to treatment complexity, unplanned hospitalizations, and symptom control were assessed based on medical records. Items related to psychological burden, family distress, or patient/parent preferences were evaluated based on follow-up interactions, multidisciplinary notes, or caregiver communication logs. Scores reflected conditions during the induction phase and were assigned prior to outcome classification to reduce potential bias.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were used to summarize patient characteristics. Continuous variables are reported as medians with interquartile ranges (IQRs); categorical variables as frequencies and percentages. Normality was assessed using histograms and the Kolmogorov-Smirnov test. Between-group comparisons were conducted using Student\u0026rsquo;s t-test or the Mann-Whitney U test for continuous variables, and the chi-square test for categorical variables.\u003c/p\u003e\u003cp\u003eDiagnostic performance metrics for the C-PaPaS, i.e., sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy\u0026mdash;were calculated using the composite reference standard. The area under the receiver operating characteristic curve (AUC) was computed to assess overall discriminative performance. The Youden Index was used to determine the optimal diagnostic cutoff score. All analyses were performed using IBM SPSS Statistics version 29.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eOf the 165 potential participants newly diagnosed with acute lymphoblastic leukemia (ALL) screened for eligibility, 12 were excluded due to loss to follow-up or inability to establish contact. The final analytic sample comprised 153 patients. Based on documented engagement with one or more palliative or supportive services, 28.1% (n\u0026thinsp;=\u0026thinsp;43) were classified into the palliative care (PPC) group, while 71.9% (n\u0026thinsp;=\u0026thinsp;110) constituted the non-PPC group (see Supplementary File 1).\u003c/p\u003e\u003cp\u003eIn the PPC group, 55.8% (n\u0026thinsp;=\u0026thinsp;24) were male, and the median age at diagnosis was 97 months (IQR: 50\u0026ndash;140.5). In the non-PPC group, 55.5% (n\u0026thinsp;=\u0026thinsp;61) were male, with a median age of 57.5 months (IQR: 38\u0026ndash;92). Compared to their counterparts, children in the PPC group were significantly more likely to be aged\u0026thinsp;\u0026ge;\u0026thinsp;10 years and to fall into a non-low-risk category at initial diagnosis (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No other demographic or clinical characteristics differed significantly between groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePPC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003enon-PPC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\varvec{\\chi\\:}}^{2}\\)\u003c/span\u003e\u003c/span\u003e/Fisher\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.968\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e55.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e45.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e2.227\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e89.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e10.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALL type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.165\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.151\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB-ALL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e91.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT-ALL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e8.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWBC count\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.145\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;50\u0026times;10⁹/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e84.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e≧\u0026thinsp;50\u0026times;10⁹/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e15.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePB blast cell\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.341\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e≧\u0026thinsp;30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e48.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e37.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e14.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBM blast cell\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.706\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.401\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e≧\u0026thinsp;95%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e43.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;95%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e56.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCNS involvement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.594\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.255\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e97.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTesticular involvement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.484\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFusion gene\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.791\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay19 MRD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.299\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.632\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e55.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e≧\u0026thinsp;0.01%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e45.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay46 MRD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e92.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e≧\u0026thinsp;0.01%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e7.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInitial risk\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e6.343\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003elow risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e66.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enon-low risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e33.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFinal risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.338\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.068\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003elow risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e53.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enon-low risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e46.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe most frequently utilized palliative services in the PPC group included nutritional, psychological, rehabilitation, and anesthesiology consultations, as well as pharmacologic pain management (e.g., tramadol). Nutrition support represented the most common service.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eC-PaPaS Scores\u003c/h3\u003e\n\u003cp\u003eAll patients were retrospectively assessed using the Chinese version of the Pediatric Palliative Screening Scale (C-PaPaS). The overall median score was 17 (IQR: 14\u0026ndash;21). Children in the PPC group had significantly higher scores (median: 23, IQR: 17\u0026ndash;25) compared to those in the non-PPC group (median: 15, IQR: 14\u0026ndash;19; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA, the boxplot shows the C-PaPaS score of the all patients. B, the boxplot shows the difference in C-PaPaS scores between PPC group and non-PPC group.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo further characterize score distribution, patients were stratified into three score bands: 10\u0026ndash;15, 15\u0026ndash;25, and 25\u0026ndash;35. The proportion of patients in each band differed significantly between PPC and non-PPC groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with higher C-PaPaS scores associated with increased likelihood of receiving PPC (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e A, The histogram shows the distribution of all patients according to the C-PaPaS scores. B, The histogram shows the difference in the distribution of two groups according to the C-PaPaS scores.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eDiagnostic Accuracy\u003c/h2\u003e\u003cp\u003eA 2\u0026times;2 diagnostic contingency table (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) was constructed using the C-PaPaS as the index test and documented PPC engagement as the reference standard. Corresponding diagnostic performance metrics, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFour-quadrant table\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePaPaS\u003c/p\u003e\u003cp\u003eScoring\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eDiagnostic standard\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePPC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003enon-PPC\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePPC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40(a)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64(b)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e104(a\u0026thinsp;+\u0026thinsp;b)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enon-PPC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(c)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46(d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49(c\u0026thinsp;+\u0026thinsp;d)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43(a\u0026thinsp;+\u0026thinsp;c)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110(b\u0026thinsp;+\u0026thinsp;d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e153(a\u0026thinsp;+\u0026thinsp;b\u0026thinsp;+\u0026thinsp;c\u0026thinsp;+\u0026thinsp;d)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDiagnostic Performance Indices Using the PaPaS Scale for Diagnosing PC needs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndices\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePaPaS Scale\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCutoff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSensitivity, %, (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93.0 (85.0,100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpecificity, %, (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.8 (32.5,51.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNPV, %, (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93.9 (86.9,100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePPV, %, (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38.5 (29.0,48.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAUROC, (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.79 (0.71\u0026ndash;0.87)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eReceiver operating characteristic (ROC) curve analysis demonstrated good discriminative performance, with an area under the curve (AUC) of 0.79 (95% CI: 0.71\u0026ndash;0.87) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The optimal diagnostic cutoff score, determined via the Youden Index, was \u0026gt;\u0026thinsp;22. At this threshold, the C-PaPaS demonstrated a specificity of 92.7% (95% CI: 0.71\u0026ndash;0.87), and a sensitivity of 51.2%, indicating strong rule-in capacity for PPC need, though with limited sensitivity to detect all eligible cases.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eReceiver operating characteristic (ROC) curve for the PaPaS scale (AUROC\u0026thinsp;=\u0026thinsp;0.79) when compared with the diagnosis standard.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study represents the first validation of the Pediatric Palliative Screening Scale (PaPaS) in mainland China, showing that the Chinese version (C-PaPaS) can reliably identify palliative care needs among children with acute lymphoblastic leukemia (ALL) during the induction chemotherapy phase. The C-PaPaS demonstrated high sensitivity (93.0%) and moderate discriminative capacity (AUC\u0026thinsp;=\u0026thinsp;0.79), aligning with growing evidence on the benefit of early PPC integration in pediatric oncology settings. \u003csup\u003e14\u003c/sup\u003e This finding supports C-PaPaS\u0026rsquo;s clinical utility as a screening tool for identifying pediatric palliative care (PPC) needs during early, high-burden phases of treatment.\u003c/p\u003e\u003cp\u003eAlthough specificity was relatively low (41.8%) compared to the optimal values (\u0026gt;\u0026thinsp;90%) reported in prior validations like those from Singapore, \u003csup\u003e6\u003c/sup\u003e this difference is likely attributable to distinct healthcare contexts and outcome definitions. The earlier studies employed long-term PPC enrollment as the endpoint, while our pragmatic reference standard focused on service engagement during a defined high-need window. In regions with nascent PPC systems like China, where structural support is evolving, documentation inconsistencies and lower referral thresholds can increase false positives. Nevertheless, high sensitivity is preferable in resource-limited settings, ensuring early triage and minimizing missed opportunities for symptom relief and supportive interventions, as emphasized in recent systematic reviews of PPC implementation in low- and middle-income countries.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOf note, high sensitivity may be an asset rather than a limitation in resource-constrained environments or healthcare systems with emerging pediatric palliative care infrastructure. In such contexts, a high-sensitivity tool like the C-PaPaS can serve as an efficient triage mechanism to ensure that no child with significant palliative needs is overlooked. This trade-off favors early over-identification to prompt further assessment\u0026mdash;a justifiable approach when access to specialist palliative services is limited or variably documented. Recent systematic reviews have emphasized the importance of inclusive screening approaches in low- and middle-income countries (LMICs), where early identification may activate existing but underutilized supportive resources and mitigate symptom escalation\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Future tiered models may therefore combine initial screening via the C-PaPaS with confirmatory assessments using clinical interviews, caregiver-reported outcomes, or validated quality-of-life instruments to improve specificity and refine referral pathways.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe optimal cutoff score identified in this study (\u0026gt;\u0026thinsp;22) is higher than those reported in prior validations, such as in Singapore and South Korea.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e This may reflect the distinct symptom burden associated with acute lymphoblastic leukemia (ALL) induction therapy, which commonly includes mucositis, gastrointestinal complications, pain, and emotional distress. Such symptoms\u0026mdash;compounded by prolonged hospitalization and treatment intensity\u0026mdash;have been shown to adversely affect both quality of life and adherence.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The C-PaPaS effectively captured this multidimensional burden, highlighting its clinical relevance in acute-phase PPC screening. However, given the study\u0026rsquo;s single-center design and reliance on retrospective documentation, caution is warranted in applying the cutoff score across other institutions or disease contexts without further validation.\u003c/p\u003e\u003cp\u003eSubgroup analysis revealed that adolescents (aged\u0026thinsp;\u0026ge;\u0026thinsp;10 years) and children classified as high-risk at diagnosis were more likely to receive palliative care services. This pattern holds important clinical implications: older children experience unique developmental vulnerabilities\u0026mdash;including increased illness awareness, body image concerns, academic disruption, and existential anxiety\u0026mdash;on top of intensified treatment burdens. Recent evidence underscores these vulnerabilities. Aretrospective study of adolescent and young adult cancer patients (aged 16\u0026ndash;39) showed that psychological factors such as anxiety, body image distress, and existential fears are prevalent and inadequately addressed during standard oncology care.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This reinforces the need for age-specific supportive interventions. The C‑PaPaS appears well-suited to identify this at-risk group by capturing a multidimensional burden across clinical, psychosocial, and familial domains. By offering standardized, proactive screening, it supports the implementation of age- and risk-adapted palliative strategies in intensive treatment settings. Such strategies can help close service gaps and ensure timely symptom management, emotional support, and psychosocial intervention for older children during induction therapy, which is an essential step toward equitable, developmentally appropriate PPC integration.\u003c/p\u003e\u003cp\u003e This study offers a practical model for adapting and implementing pediatric palliative care,screening tools in settings where PPC systems are still emerging. While China is not an LMIC, its pediatric oncology PPC infrastructure remains underdeveloped, with limited standardization, cultural barriers, and variable referral practices. \u003csup\u003e17\u003c/sup\u003e By demonstrating the cultural adaptation and validation of the PaPaS in an acute pediatric oncology context, our findings provide transferable insights for health systems facing similar challenges. The use of a high-sensitivity tool like the C-PaPaS for early triage\u0026mdash;paired with follow-up assessment through clinical or caregiver-reported measures\u0026mdash;aligns with global early-phase PPC integration strategies. This approach, supported by pragmatic service-based reference standards, may inform scalable PPC implementation across diverse care settings. \u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study has several limitations. It was conducted at a single tertiary pediatric oncology center with a moderate sample size, potentially limiting generalizability across institutions and health systems. The relatively homogeneous cohort restricted exploration of contextual factors such as socioeconomic variation or regional disparities that may influence palliative care access. The retrospective design relied on routine clinical documentation, which may have introduced inconsistencies in data completeness and accuracy, affecting both C-PaPaS scoring and classification of palliative care engagement. Additionally, in China\u0026rsquo;s early-stage PPC landscape, where services are embedded in general supportive care and lack formal referral pathways, our use of a pragmatic, service-based reference standard may have underestimated unmet needs or misclassified borderline cases. Nevertheless, it holds the potential of offering a feasible method for real-world classification when prospective adjudication is not available.\u003c/p\u003e\u003cp\u003eGiven that the original PaPaS has been validated in high-income countries, this study contributes important evidence supporting its cultural adaptation and real-world application in a health system where PPC is still emerging. To further strengthen the utility of the C-PaPaS, future research should include larger, multicenter, and prospectively designed studies that incorporate diverse demographic and healthcare settings. Cross-system validation, especially in mature PPC environments, will help benchmark diagnostic performance and guide international adaptation. Refinements to the scoring algorithm, e.g., differential weighting or machine learning\u0026ndash;based optimization may improve diagnostic precision. Integrating the C-PaPaS into a tiered screening model, followed by structured clinical interviews or caregiver-reported outcomes, could enhance specificity while maintaining its triage value. Such a strategy aligns with global implementation science frameworks and may accelerate PPC integration in pediatric oncology settings with varying resource levels.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that the C-PaPaS is a feasible and sensitive tool for identifying palliative care needs in children with acute lymphoblastic leukemia during induction therapy. The scale showed good diagnostic performance, particularly in detecting high-need cases in a setting where PPC services are still developing. While specificity was limited, the C-PaPaS offers a practical approach to support early screening and referral in pediatric oncology.\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003cp\u003e\u003cstrong\u003ePPC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePediatric palliative care\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePaPaS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePediatric palliative care screening scale\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eALL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcute lymphoblastic leukemia\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCCCG-ALL-2020\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChinese Children\u0026rsquo;s Cancer Group Acute Lymphoblastic Leukemia 2020 protocol\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC-PaPaS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChinese version of the pediatric palliative care screening scale\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eROC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReceiver Operating Characteristic\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTARD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStandards for Reporting of Diagnostic Accuracy Studies\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEMR\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eElectronic Medical Record\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCNS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCentral Nervous System\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMinimal Residual Disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMDT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMultidisciplinary Team\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterquartile Range\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePPV\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePositive Predictive Value\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNPV\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNegative Predictive Value\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eArea Under the Curve\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMICs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the patients and their families who participated in this study, as well as the multidisciplinary team at the Children\u0026rsquo;s Hospital of Fudan University for their support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe work was supported by the National Key Research and Development Program of China (No. 2023YFC2706301), National Key Research and Development Program of China (No. 2022YFC2705003), National Natural Science Foundation of China (82141125), Science and Technology Commission of Shanghai Municipality (21Y31900302). China Medical Board Open Competition Grant (#21-427)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available upon the request from the corresponding coauthor Xiaowen Zhai.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLei Cheng obtained permission from the original author to use and translate the scale. Alidannu nueraili, Junye Jiang, Hongsheng Wang, Lei Cheng, Xiaowen zhai Completed the translation, linguistic adaptation of the scale, contributed to the analysis plan, and interpretation of findings. Alidannu Nueraili conducted the data analysis,and drafted the manuscript. Junye jiang, Hongsheng Wang, Xiaohua Zhu, Yi Yu, Ping Cao, Yang FU, Jun Li, Ling Yu, Lei Cheng, Xiaowen Zhai reviewed the manuscript, revised it critically for important intellectual content, and edited it to make it read well in English. Xiaowen Zhai was responsible for the study design, supervised the study, led the data collection, revise the manuscript, and approval of the final draft. Alidannu Nueraili, Junye Jiang, and Hongsheng Wang contributed equally to this work as co-first authors.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study has been reviewed and approved by the Ethics Committee of the Children\u0026apos;s Hospital of Fudan University (registration number 2021/512). Informed consent to participate was obtained from all participants (or their legal guardians). The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoucher NA, Johnson KS, LeBlanc TW. Acute Leukemia Patients' Needs: Qualitative Findings and Opportunities for Early Palliative Care. J Pain Symptom Manage. 2018;55(2):433\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConnor SR, Downing J, Marston J. Estimating the Global Need for Palliative Care for Children: A Cross-sectional Analysis. J Pain Symptom Manage. 2017;53(2):171\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCai S, Guo Q, Wang X, et al. Development levels of pediatric palliative care teams and the extent of palliative care understanding and implementation among pediatric oncologists in China. Pediatr Investig. 2021;5(4):265\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu L, Wu M, Cheng L et al. Chinese Providers' Perspectives on Early Integration of Palliative Care in Pediatric Oncology: A Mixed-Methods Study. Cancer Nurs 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBergstraesser E, Hain RD, Pereira JL. The development of an instrument that can identify children with palliative care needs: the Paediatric Palliative Screening Scale (PaPaS Scale): a qualitative study approach. BMC Palliat Care. 2013;12(1):20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChong PH, Soo J, Yeo ZZ, Ang RQ, Ting C. Who needs and continues to need paediatric palliative care? An evaluation of utility and feasibility of the Paediatric Palliative Screening scale (PaPaS). BMC Palliat Care. 2020;19(1):18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSong IG, Kwon SY, Chang YJ, et al. Paediatric palliative screening scale as a useful tool for clinicians' assessment of palliative care needs of pediatric patients: a retrospective cohort study. BMC Palliat Care. 2021;20(1):73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndriastuti M, Halim PG, Kusrini E, Bangun M. Correlation of Pediatric Palliative Screening Scale and Quality of Life in Pediatric Cancer Patients. Indian J Palliat Care. 2020;26(3):338\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUgaz C, Ortiz I, Soto G, Morales R, Vasquez L. Pediatric Palliative Screening Scale in pediatric cancer patients: A qualitative study approach. Pediatr Blood Cancer. 2021;68(12):e29249.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNi X, Li Z, Li X, et al. Socioeconomic inequalities in cancer incidence and access to health services among children and adolescents in China: a cross-sectional study. Lancet. 2022;400(10357):1020\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou YL, An JL, Tian L. Epidemiological analysis of childhood cancer in China. Chin J Contemp Pediatr. 2015;17(7):649\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi R, Shen X, Yang Q, et al. Stability of Symptom Clusters in Children With Acute Lymphoblastic Leukemia Undergoing Chemotherapy. Cancer Nurs. 2024;47(5):E348\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFerraz A, Santos M, Pereira MG. Parental distress in childhood acute lymphoblastic leukemia: A systematic review of the literature. J Fam Psychol. 2024;38(1):149\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLacerda A, Mart\u0026iacute;nez MA, Dumont B et al. Embracing paediatric palliative care in paediatric oncology from diagnosis onwards. Pediatr Blood Cancer 2023:e30561.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKenneson SA, Hughes-Visentin A, Wrigley J, et al. Pediatric Palliative Care Program Implementation in LMICs: A Systematic Review using SWOT Analysis. J Pain Symptom Manage. 2023;66(4):338\u0026ndash;e350311.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaub S, Macauley R. Early and often: Promoting early integration of pediatric palliative care for seriously ill children with cancer. Curr Probl Cancer. 2023;47(5):101023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatanabe H, Watanabe A, Fujikawa K, et al. Characteristics of adolescent and young adult patients with cancer receiving home-based palliative care: A retrospective study at a single center. Support Care Cancer. 2024;32(11):748.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManiago JD, Ngaya-An FV. Implementation Science of Paediatric Palliative Care in Lower-Middle-Income Countries in Southeast Asia: An Integrative Review. Indian J Palliat Care. 2022;28(1):80\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pediatric palliative care, pediatric palliative screening scale, diagnostic accuracy, sensitivity and specificity","lastPublishedDoi":"10.21203/rs.3.rs-7808438/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7808438/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTimely identification of pediatric palliative care (PPC) needs is essential to improving the quality of life for children with life-threatening illnesses. The Pediatric Palliative Screening Scale (PaPaS) has been validated internationally, but it has not yet been evaluated in mainland China, where PPC infrastructure remains limited and fragmented. The aim of this study is to adapt the PaPaS into Chinese and evaluate its diagnostic performance in identifying PPC needs among children with acute lymphoblastic leukemia (ALL) during induction chemotherapy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective diagnostic accuracy study included children aged 0\u0026ndash;18 years newly diagnosed with ALL who initiated induction therapy under the CCCG-ALL-2020 protocol at a tertiary pediatric hospital in China (August 2020\u0026ndash;August 2023). The Chinese version of the PaPaS (C-PaPaS) was developed through forward\u0026ndash;backward translation and expert review. Scores were retrospectively assigned using electronic medical records. Receiver operating characteristic (ROC) analysis was used to assess diagnostic performance and identify the optimal cutoff.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong 153 patients, 28.1% received PPC interventions. Median C-PaPaS scores were significantly higher in the PPC group (23 [IQR 17\u0026ndash;25]) than in the non-PPC group (15 [14\u0026ndash;19]; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). At a cutoff score of \u0026gt;\u0026thinsp;22, the C-PaPaS demonstrated high sensitivity (93.0%) and moderate specificity (41.8%), with an area under the ROC curve of 0.79 (95% CI: 0.71\u0026ndash;0.87).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe C-PaPaS demonstrated strong sensitivity and moderate discriminative accuracy in identifying PPC needs among children with ALL. It may serve as a useful triage tool to support early palliative integration, especially in settings with limited PPC infrastructure.\u003c/p\u003e","manuscriptTitle":"Identifying Palliative Care Needs in Children with Acute Lymphoblastic Leukemia: Validation of the Chinese Pediatric Palliative Screening Scale (C-PaPaS)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 07:01:56","doi":"10.21203/rs.3.rs-7808438/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-26T21:30:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T14:02:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232873869422645268923253738483748914045","date":"2026-01-22T12:31:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234692307229983221734391507103449458831","date":"2026-01-21T09:32:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T09:56:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27939299481185158393822984992871165226","date":"2026-01-07T05:34:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127606892023225983930351164976695430575","date":"2026-01-05T08:09:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-14T06:56:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-14T06:46:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-30T10:51:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-30T10:41:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-10-30T10:38:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c2e237db-910e-40ea-9ee7-832614a8cd5c","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:04:10+00:00","versionOfRecord":{"articleIdentity":"rs-7808438","link":"https://doi.org/10.1186/s12904-026-02080-6","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2026-04-17 15:58:46","publishedOnDateReadable":"April 17th, 2026"},"versionCreatedAt":"2025-11-26 07:01:56","video":"","vorDoi":"10.1186/s12904-026-02080-6","vorDoiUrl":"https://doi.org/10.1186/s12904-026-02080-6","workflowStages":[]},"version":"v1","identity":"rs-7808438","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7808438","identity":"rs-7808438","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}