Background: Spiritual care is recognized as an essential component of standard care for children with cancer and their families. Oncologists lack training in navigating spirituality discussions in primary cancer care. The current landscape of spiritual dialogue during clinical oncology encounters remains understudied. Procedures: This qualitative study aimed to describe the frequency, context, and content of religious and spiritual communication between pediatric neuro-oncologists, caregivers, and patients with brain tumors during disease reevaluation encounters. This study is part of the U-CHAT trial (NCT02846038), a prospective longitudinal investigation of realtime clinical communication across the trajectory of poor prognosis cancer. Patients with brain tumors and their caregivers were eligible if their primary oncologist estimated survival ≤ 50%. All disease reevaluation encounters for enrolled patients were audiorecorded and underwent rapid qualitative analysis to identify, summarize, and synthesize religious and spiritual communication. Results: Religious or spiritual references were identified in 23 (18%) of 129 total encounters. References usually comprised a single religious or spiritual term, with “prayer”-related language representing the majority of references. Caregivers introduced spirituality dialogue more often than oncologists (65% vs 35%). References were most often identified in the context of discussion about an uncertain or uncontrollable future. Conclusions: Results suggest oncologists rarely integrate spiritual care into disease reevaluation discussions. In light of recommendations from multiple consensus groups to integrate spiritual care into cancer care, future work should explore how generalist spiritual care training could better equip oncologists to attend to spiritual needs that arise along the cancer trajectory.