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PURPOSE Communication breakdowns in pediatric oncology can have negative consequences for patients and families. A detailed analysis of these negative encounters will support clinicians in anticipating and responding to communication breakdowns. METHODS Semistructured interviews with 80 parents of children with cancer across three academic medical centers during treatment, survivorship, or bereavement. We analyzed transcripts using semantic content analysis. RESULTS Nearly all parents identified negative communication experiences (n 5 76). We identified four categories of contributors to negative experiences: individual (n 5 68), team (n 5 26), organization (n 5 46), and greater health care system (n 5 8). These experiences involved a variety of health care professionals across multiple specialties. Parents reported 12 personal consequences of communication breakdowns: emotional distress (n 5 65), insufficient understanding (n 5 48), decreased trust or confidence (n 5 37), inconvenience (n 5 36), medical harm (n 5 23), decreased self-confidence (n 5 17), decreased emotional support (n 5 13), decreased engagement (n 5 9), false hope (n 5 9), decreased hope (n 5 7), financial insult (n 5 7), and decreased access to resources (n 5 3). We identified five categories of supportive responses from clinicians: exploring (n 5 8), acknowledging (n 5 17), informing (n 5 27), adapting (n 5 27), and advocating (n 5 18). Parents often increased their own advocacy on behalf of their child (n 5 47). Parents also identified the need for parental engagement in finding solutions (n 5 12). Finally, one parent suggested that clinicians should assume that communication will fail and develop contingency plans in advance. CONCLUSION Communication breakdowns in pediatric oncology negatively affect parents and children. Clinicians should plan for communication breakdowns and respond by exploring, acknowledging, informing, adapting, advocating, and engaging parents in finding solutions. [ABSTRACT FROM AUTHOR]