Inequities in Pediatric Cancer: Unveiling the Impact of Social Determinants of Health on Survival
Charbel Chidiac
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorPallavi Menon
Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorMark B. Slidell
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorShaun M. Kunisaki
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorAlejandro V. Garcia
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorCorresponding Author
Daniel S. Rhee
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorCharbel Chidiac
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorPallavi Menon
Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorMark B. Slidell
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorShaun M. Kunisaki
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorAlejandro V. Garcia
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorCorresponding Author
Daniel S. Rhee
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Search for more papers by this authorFunding: No funding was secured for this study.
ABSTRACT
Background
The implications of sociodemographic factors across a wide range of pediatric cancers remain unclear. This study aims to assess the impact of social determinants of health (SDOH) on the survival rates of children diagnosed with cancer.
Methods
This retrospective cohort study included children <18 years with cancer in the National Cancer Database (2004–2020). Cancers included were central nervous system (CNS) tumors, leukemia, lymphoma, and non-CNS solid tumors. The primary outcome was five-year overall survival (5-OS). Kaplan–Meier curves and multivariable Cox proportional regression were employed.
Results
Of 132,076 children (median age 8 years), 14.8% had CNS tumors, 47.4% leukemia/lymphoma, and 37.8% had non-CNS solid tumors. The median follow-up was 67.3 months. 5-OS was lower in Black (78.9% vs. 84.9%, p < 0.001) and Hispanic (82.1% vs. 84.3%, p < 0.001) children, and those publicly insured (82.1%) and noninsured (80.2%) compared with privately insured (85.8%) (p < 0.001). On multivariable analysis, factors associated with increased hazard of death were Black race (aHR 1.28, 95% CI 1.23–1.34), Hispanic ethnicity (aHR 1.08, 95% CI 1.03–1.12), areas with <93% parental high school graduation (aHR 1.20, 95% CI 1.14–1.25), median household income <$63,331 (aHR 1.11, 95% CI 1.06–1.16), nonprivate insurance (aHR 1.16, 95%CI 1.12-1.20), no insurance (aHR 1.36, 95% CI 1.24–1.49), living in rural/urban areas (aHR 1.05, 95% CI 1.01–1.10) and living ≥60 miles from the treating facility (aHR 1.20, 95% CI 1.15–1.24).
Conclusions
SDOH are associated with disparities in pediatric cancer survival rates. Targeted strategies to enhance care for Black and Hispanic children, as well as those with limited access due to insurance and travel distance, are essential for achieving equitable outcomes for all pediatric cancer patients.
Conflicts of Interest
The authors have no conflicts of interest relevant to this article to disclose.
Open Research
Data Availability Statement
The data that support the findings of this study are openly available in the National Cancer Database at https://www.facs.org/quality-programs/cancer/ncdb.
Supporting Information
| Filename | Description |
|---|---|
| pbc31742-sup-0001-SuppMat1.docx47.4 KB | Supporting information |
| pbc31742-sup-0002-SuppMat2.docx72.3 MB | Supporting information |
| pbc31742-sup-0003-SuppMat3.docx47.2 KB | Supporting information |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
References
- 1M. Bruce, “A Systematic and Conceptual Review of Posttraumatic Stress in Childhood Cancer Survivors and Their Parents,” Clinical Psychology Review 26 (2006): 233–256, https://doi.org/10.1016/j.cpr.2005.10.002.
- 2“ Key Statistics for Childhood Cancers,” accessed May 9, 2024, https://www.cancer.org/cancer/types/cancer-in-children/key-statistics.html.
- 3A. Beltrami, A. Hilliard, and A. L. Green, “Demographic and Socioeconomic Disparities in Pediatric Cancer in the United States: Current Knowledge, Deepening Understanding, and Expanding Intervention,” Cancer Epidemiology 76 (2022): 102082, https://doi.org/10.1016/j.canep.2021.102082.
- 4“ Social Determinants of Health,” accessed December 19, 2024, https://www.who.int/health-topics/social-determinants-of-health.
- 5“ Social Determinants of Health—Healthy People 2030,” Odphp.Health.Gov, accessed December 19, 2024, https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health.
- 6W. Powell, J. Richmond, D. Mohottige, I. Yen, A. Joslyn, and G. Corbie-Smith, “Medical Mistrust, Racism, and Delays in Preventive Health Screening among African-American Men,” Behavioral Medicine 45 (2019): 102–117, https://doi.org/10.1080/08964289.2019.1585327.
- 7L. B. Adams, J. Richmond, G. Corbie-Smith, and W. Powell, “Medical Mistrust and Colorectal Cancer Screening among African Americans,” Journal of Community Health 42 (2017): 1044–1061, https://doi.org/10.1007/s10900-017-0339-2.
- 8N. J. Nonzee, D. M. Ragas, T. Ha Luu, et al., “Delays in Cancer Care among Low-Income Minorities Despite Access,” Journal of Women's Health 24 (2015): 506–514, https://doi.org/10.1089/jwh.2014.4998.
- 9P. Aristizabal, A. K. Ma, N. V. Kumar, et al., “Assessment of Factors Associated with Parental Perceptions of Voluntary Decisions about Child Participation in Leukemia Clinical Trials,” JAMA Network Open 4 (2021): e219038, https://doi.org/10.1001/jamanetworkopen.2021.9038.
- 10J. M. Berkman, J. Dallas, J. Lim, et al., “Social Determinants of Health Affecting Treatment of Pediatric Brain Tumors,” Journal of Neurosurgery: Pediatrics 24 (2019): 159–165, https://doi.org/10.3171/2019.4.PEDS18594.
- 11P. Aristizabal, L. Winestone, P. Umaretiya, and K. Bona, “Disparities in Pediatric Oncology: The 21st Century Opportunity to Improve Outcomes for Children and Adolescents with Cancer” American Society of Clinical Oncology Educational Book American Society of Clinical Oncology Annual Meeting 2021, 41, e315, https://doi.org/10.1200/EDBK_320499.
- 12P. Braveman and L. Gottlieb, “The Social Determinants of Health: It's Time to Consider the Causes of the Causes,” Public Health Reports 129 (2014): 19–31.
- 13V. Chalfant, C. Riveros, S. M. Bradfield, and A. A. Stec, “Impact of Social Disparities on 10 Year Survival Rates in Paediatric Cancers: A Cohort Study,” The Lancet Regional Health – Americas 20 (2023): 100454, https://doi.org/10.1016/j.lana.2023.100454.
- 14J. Zhao, X. Han, Z. Zheng, et al., “Racial/Ethnic Disparities in Childhood Cancer Survival in the United States,” Cancer Epidemiology and Prevention Biomarkers 30 (2021): 2010–2017, https://doi.org/10.1158/1055-9965.EPI-21-0117.
- 15R. D. Kehm, L. G. Spector, J. N. Poynter, D. M. Vock, S. F. Altekruse, and T. L Osypuk, “Does Socioeconomic Status Account for Racial and Ethnic Disparities in Childhood Cancer Survival?,” Cancer 2018, 124, 4090–4097, https://doi.org/10.1002/cncr.31560.
- 16“ The Commission on Cancer: A 10-Decade Perspective,” accessed December 19, 2024, https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2022/01/the-commission-on-cancer-a-10-decade-perspective/.
- 17“ National Cancer Database,” accessed December 19, 2024, https://www.facs.org/quality-programs/cancer-programs/national-cancer-database/.
- 18“ USDA ERS: Rural–Urban Continuum Codes,” accessed December 19, 2024, https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/.
- 19R. W. Sinnott, “Virtues of the Haversine,” Sky & Telescope 68 (1984): 158.
- 20E. B. Dean, M. T. French, and K. Mortensen, “Food Insecurity, Health Care Utilization, and Health Care Expenditures,” Health Services Research 55, no. 2 (2020): 883–893, https://doi.org/10.1111/1475-6773.13283. Suppl.
- 21T. J. Reeves, T. J. Mathis, H. E. Bauer, et al., “Racial and Ethnic Disparities in Health Outcomes among Long-Term Survivors of Childhood Cancer: A Scoping Review,” Frontiers in Public Health 9 (2021): 741334, https://doi.org/10.3389/fpubh.2021.741334.
- 22M. Davitt, L. Gennarini, D. Loeb, M. Fazzari, and H. D. Hosgood, “Impact of Race/Ethnicity and Language Preferences on Pediatric all Survival Outcomes,” Cancer Medicine 12 (2023): 12827–12836, https://doi.org/10.1002/cam4.5951.
- 23G. K. Singh, G. P. Daus, M. Allender, et al., “Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935–2016,” Int J MCH AIDS 6 (2017): 139–164, doi:10.21106/ijma.236.
- 24S. Bhatia, “Disparities in Cancer Outcomes: Lessons Learned From Children With Cancer” Pediatric Blood & Cancer 2011, 56, 994–1002, https://doi.org/10.1002/pbc.23078.
- 25K. Bona, Y. Li, L. E. Winestone, et al., “Poverty and Targeted Immunotherapy: Survival in Children's Oncology Group Clinical Trials for High-Risk Neuroblastoma,” JNCI: Journal of the National Cancer Institute 113 (2021): 282–291, https://doi.org/10.1093/jnci/djaa107.
- 26A. Delavar, O. M. Al Jammal, K. R. Maguire, A. R. Wali, and M. H. Pham, “The Impact of Rural Residence on Adult Brain Cancer Survival in the United States,” Journal of Neuro-Oncology 144 (2019): 535–543, https://doi.org/10.1007/s11060-019-03254-4.
- 27A. M. Linabery and J. A. Ross, “Childhood and Adolescent Cancer Survival in the US by Race and Ethnicity for the Diagnostic Period 1975–1999” Cancer 2008, 113, 2575–2596, https://doi.org/10.1002/cncr.23866.
- 28N. S. Kadan-Lottick, K. K. Ness, S. Bhatia, and J. G. Gurney, “Survival Variability by Race and Ethnicity in Childhood Acute Lymphoblastic Leukemia,” Jama 290 (2003): 2008–2014, https://doi.org/10.1001/jama.290.15.2008.
- 29S. Bhatia, H. N. Sather, N. A. Heerema, M. E. Trigg, P. S. Gaynon, and L. L. Robison, “Racial and Ethnic Differences in Survival of Children With Acute Lymphoblastic Leukemia,” Blood 100 (2002): 1957–1964, https://doi.org/10.1182/blood-2002-02-0395.
- 30B. H. Pollock, M. R. DeBaun, B. M. Camitta, et al., “Racial Differences in the Survival of Childhood B-Precursor Acute Lymphoblastic Leukemia: A Pediatric Oncology Group Study,” Journal of Clinical Oncology 18 (2000): 813–813, https://doi.org/10.1200/JCO.2000.18.4.813.
- 31S. H. Armenian and S. Bhatia, “Chronic Health Conditions in Childhood Cancer Survivors: Is It All Treatment-Related–or Do Genetics Play a Role?,” Journal of General Internal Medicine 24, no. 2 (2009): S395–400, https://doi.org/10.1007/s11606-009-0995-8. Suppl.
- 32“ How Racism Is a Structural and Social Determinant of Health,” accessed April 2, 2025, https://wexnermedical.osu.edu/our-stories/racism-is-a-social-determinant-of-health.
- 33B. U. S. Novakovic, “Childhood Cancer Survival, 1973–1987,” Medical and Pediatric Oncology 23 (1994): 480–486, https://doi.org/10.1002/mpo.2950230606.
- 34N. Morshed and F. B. Zhan, “Racial/Ethnic, Social Characteristics and Geographic Disparities of Childhood Cancer Late-Stage Diagnosis in Texas, 2005 to 2014,” Annals of GIS 27 (2021): 329–340, https://doi.org/10.1080/19475683.2021.1981999.
- 35P. Tehranifar, A. I. Neugut, J. C. Phelan, et al., “Medical Advances and Racial/Ethnic Disparities in Cancer Survival,” Cancer Epidemiology and Prevention Biomarkers 18 (2009): 2701–2708, https://doi.org/10.1158/1055-9965.EPI-09-0305.
- 36J. M. Unger, A. B. Moseley, C. K. Cheung, et al., “Persistent Disparity: Socioeconomic Deprivation and Cancer Outcomes in Patients Treated in Clinical Trials,” Journal of Clinical Oncology 39 (2021): 1339–1348, https://doi.org/10.1200/JCO.20.02602.
- 37D. Sarfati “ Why Social Inequalities Matter in the Cancer Continuum,” in Reducing Social Inequalities in Cancer: Evidence and Priorities for Research, ed. S. Vaccarella, J. Lortet-Tieulent, R. Saracci, D. I. Conway, K. Straif, C.P. Wild (International Agency for Research on Cancer, 2019).
- 38G. Alicandro, P. Bertuccio, G. Sebastiani, C. La Vecchia, and L. Frova, “Parental Education and Cancer Mortality in Children, Adolescents, and Young Adults: A Case-Cohort Study Within the 2011 Italian Census Cohort,” Cancer 2020, 126, 4753–4760, https://doi.org/10.1002/cncr.33146.
- 39A. Tolkkinen, L. Madanat-Harjuoja, M. Taskinen, M. Rantanen, N. Malila, and J. Pitkäniemi, “Impact of Parental Socioeconomic Factors on Childhood Cancer Mortality: A Population-Based Registry Study,” Acta Oncologica 57 (2018): 1547–1555, https://doi.org/10.1080/0284186X.2018.1478125.
- 40C. Metayer, G. Dahl, J. Wiemels, and M. Miller, “Childhood Leukemia: A Preventable Disease,” Pediatrics 138 (2016): S45–S55, https://doi.org/10.1542/peds.2015-4268H.
- 41C. Metayer, E. Petridou, J. M. M. Aranguré, et al., “Parental Tobacco Smoking and Acute Myeloid Leukemia: The Childhood Leukemia International Consortium,” American Journal of Epidemiology 184 (2016): 261–273, https://doi.org/10.1093/aje/kww018.
- 42S. L. Stacy, J. M. Buchanich, Z. Ma, et al., “Maternal Obesity, Birth Size, and Risk of Childhood Cancer Development,” American Journal of Epidemiology 188 (2019): 1503–1511, https://doi.org/10.1093/aje/kwz118.
- 43A. Lewandowska, “The Needs of Parents of Children Suffering From Cancer-Continuation of Research,” Children (Basel) 9 (2022): 144, https://doi.org/10.3390/children9020144.
- 44N. L. Penumarthy, R. E. Goldsby, S. C. Shiboski, R. Wustrack, P. Murphy, and L. E. Winestone, “Insurance Impacts Survival for Children, Adolescents, and Young Adults With Bone and Soft Tissue Sarcomas,” Cancer Medicine 9 (2020): 951–958, https://doi.org/10.1002/cam4.2739.
- 45J. R. Fine, J. M. Ransdell, P. S. Pinheiro, et al., “The Effect of Health Insurance on Pediatric Cancer Survival: An Analysis of Children Evaluated for Radiation Therapy in Diverse Multicenter Health Systems,” Journal of Pediatric Hematology/Oncology 45 (2023): e662–e670, https://doi.org/10.1097/MPH.0000000000002678.
- 46J. M. Lee, X. Wang, R. P. Ojha, and K. J. Johnson, “The Effect of Health Insurance on Childhood Cancer Survival in the United States,” Cancer 123 (2017): 4878–4885, https://doi.org/10.1002/cncr.30925.
- 47S. L. Dickman, D. U. Himmelstein, and S. Woolhandler, “Inequality and the Health-Care System in the USA,” Lancet 389 (2017): 1431–1441, https://doi.org/10.1016/S0140-6736(17)30398-7.
- 48P. Afulani, D. Herman, A. Coleman-Jensen, and G. G. Harrison, “Food Insecurity and Health Outcomes among Older Adults: The Role of Cost-Related Medication Underuse,” Journal of Nutrition in Gerontology and Geriatrics 34 (2015): 319–342, https://doi.org/10.1080/21551197.2015.1054575.
- 49D. Herman, P. Afulani, A. Coleman-Jensen, and G. G. Harrison, “Food Insecurity and Cost-Related Medication Underuse Among Nonelderly Adults in a Nationally Representative Sample,” American Journal of Public Health 105 (2015): e48–e59, https://doi.org/10.2105/AJPH.2015.302712.
- 50A. M. Tarnasky, L. A. Olivere, L. Ledbetter, and E. T. Tracy, “Examining the Effect of Travel Distance to Pediatric Cancer Centers and Rurality on Survival and Treatment Experiences: A Systematic Review,” Journal of Pediatric Hematology/Oncology 43 (2021): 159–171, https://doi.org/10.1097/MPH.0000000000002095.
- 51P. Kattner, H. Strobel, N. Khoshnevis, et al., “Compare and Contrast: Pediatric Cancer versus Adult Malignancies,” Cancer and Metastasis Reviews 38 (2019): 673–682, https://doi.org/10.1007/s10555-019-09836-y.
- 52A. Kumar, Z. D. Guss, P. T. Courtney, et al., “Evaluation of the Use of Cancer Registry Data for Comparative Effectiveness Research,” JAMA Network Open 3 (2020): e2011985, https://doi.org/10.1001/jamanetworkopen.2020.11985.
