Socioeconomic disparities in survival after high-risk neuroblastoma treatment with modern therapy
Daniel J. Zheng and Anran Li contributed equally as co-first authors.
Kira Bona and Jonathan M. Marron contributed equally as co-senior authors.
An earlier version of this work was presented in part at the 2014 International Society of Paediatric Oncology (SIOP) Annual Meeting in Toronto, Canada.
Abstract
Background
Modern therapeutic advances in high-risk neuroblastoma have improved overall survival (OS), but it is unclear whether these survival gains have been equitable. This study examined the relationship between socioeconomic status (SES) and overall survival (OS) in children with high-risk neuroblastoma and whether SES-associated disparities have changed over time.
Procedure
In this population-based cohort study, children <18 years diagnosed with high-risk neuroblastoma (diagnosis at age ≥12 months with metastatic disease) from 1991 to 2015 were identified through the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Associations of county-level SES variables and OS were tested with univariate Cox proportional hazards regression. For a subcohort diagnosed after 2007, insurance status was examined as an individual-level SES variable. Multivariable regression analyses with treatment era and interaction terms were performed when SES variables reached near-significance (p ≤ .1) in univariate and bivariate modeling with treatment era.
Results
Among 1217 children, 2-year OS improved from 53.0 ± 3.4% in 1991–1998 to 76.9 ± 2.9% in 2011–2015 (p < .001). In univariate analyses, children in high-poverty counties (hazard ratio [HR] = 1.74, 95% confidence interval [CI] = 1.17–2.60, p = .007), and those with Medicaid (HR = 1.40, 95% CI = 1.05–1.86, p = .02) experienced an increased hazard of death. No interactions between treatment era and SES variables were statistically significant in multivariable analyses, indicating that differences in the OS between SES groups did not change over time.
Conclusions
Survival disparities among children with high-risk neuroblastoma have not widened over time, suggesting equitable access to and benefit from therapeutic advances. However, children of low SES experience persistently inferior survival. Interventions to narrow this disparity are paramount.
CONFLICT OF INTEREST
Jonathan M. Marron receives payment for participation on the Ethics Advisory Board of Partner Therapeutics for work unrelated to this research study. The remaining authors have no relevant conflicts of interest to disclose.
