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Original Investigation
February 24, 2020

Associations Between Race/Ethnicity and US Childhood and Adolescent Cancer Survival by Treatment Amenability

Author Affiliations
  • 1Medical Student, University of California, San Diego, School of Medicine, La Jolla
  • 2Brown School Master of Public Health Program, Washington University in St Louis, St Louis, Missouri
  • 3Medical Student, St Louis University School of Medicine, St Louis, Missouri
  • 4Siteman Cancer Center, Washington University in St Louis, St Louis, Missouri
JAMA Pediatr. 2020;174(5):428-436. doi:10.1001/jamapediatrics.2019.6074
Key Points

Question  Are racial/ethnic disparities in childhood and adolescent cancer survival associated with treatment amenability?

Finding  In this cohort study of 67 061 US children and adolescents, children and adolescents with racial/ethnic minority status had worse cancer survival compared with non-Hispanic white children and adolescents. Among non-Hispanic black and Hispanic (all races) children and adolescents, the disparity was generally greater for cancer types with higher vs lower relative survival rates.

Meaning  Survival disparities among racial/ethnic minority children and adolescents appear to be greater for cancer types that are generally more amenable to medical intervention.

Abstract

Importance  Although US cancer survival rates have increased over time, disparities by race/ethnicity remain, including for children and adolescents.

Objective  To examine whether racial/ethnic disparities in childhood and adolescent cancer survival vary by cancer type according to relative survival rates (RSRs), a marker for amenability to medical intervention.

Design, Setting, and Participants  In a retrospective cohort study using US Surveillance, Epidemiology, and End Results data, 67 061 children and adolescents diagnosed at ages 0 to 19 years with a first primary malignant cancer from January 1, 2000, to December 31, 2016, were evaluated. Data analysis was performed from June 19 to November 3, 2019. Participants were followed up from the dates of diagnosis to cancer death or the end of the follow-up period, whichever came first.

Exposures  Race/ethnicity defined as non-Hispanic white, non-Hispanic black, non-Hispanic American Indian/Alaskan Native, non-Hispanic Asian or Pacific Islander, or Hispanic (any race).

Main Outcomes and Measures  Cancer amenability was defined using 5-year RSRs for 103 cancer types. Cox proportional hazards regression was used to compute adjusted hazard ratios (aHRs) and 95% CIs for the association between race/ethnicity and cancer survival for high (>85% RSR), medium (70%-85% RSR), and low (<70% RSR) amenability categories.

Results  Among 67 061 cancer cases, 36 064 were male (53.8%); most individuals were non-Hispanic white (35 186 [52.5%]) followed by Hispanic of any race (19 220 [28.7%]), non-Hispanic black (7100 [10.6%]), non-Hispanic Asian or Pacific Islander (4981 [7.4%]), and non-Hispanic American Indian/Alaskan Native (574 [0.9%]). Mean (SD) age at diagnosis was 9.66 (6.41) years. Compared with non-Hispanic white children and adolescents, a higher aHR of death was observed for high- than low-amenability cancers for non-Hispanic black patients (high: aHR, 1.59; 95% CI, 1.41-1.80 vs low: aHR, 1.35; 95% CI, 1.24-1.47; P = .002 for interaction) and Hispanic (any race) patients (high: aHR, 1.63; 95% CI, 1.50-1.78 vs low: aHR, 1.16; 95% CI, 1.08-1.25; P < .001 for interaction). Results for other race/ethnicities showed similar patterns but were not statistically significant.

Conclusions and Relevance  Racial/ethnic minority children and adolescents were observed to have a higher risk of death than non-Hispanic white children and adolescents, with more amenable cancers having larger relative survival differences. This disparity may be associated with a combination of factors, including differences in access to health care resources.

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    1 Comment for this article
    EXPAND ALL
    Relative Differences in Survival And Mortality Are Not the Same Thing
    James Scanlan, JD | Attorney at Law
    This article appears to fall within a large body of research that discusses relative differences in
    survival and relative differences in mortality interchangeably, often stating it is examining survival differences while in fact examining mortality differences. Invariably, such research has failed to recognize that that as survival generally increases, relative differences in survival tend to decrease while relative differences in mortality tend to increase, or that more survivable cancers tend to show smaller relative differences in survival but larger relative differences in mortality than less survivable cancers See reference 1 at 334 and the discussion of
    Tables 10 and 11 of reference 2. To my knowledge, no discussion of demographic differences in cancer outcomes has recognized that it is even possible for relative differences in survival and relative differences in mortality to show opposite patterns as to directions of changes over time or the comparative size of differences as to different types of cancers much less that this tends to occur systematically. The contrasting patterns may not always be present. But it is not possible to draw inferences about processes or the effects of interventions on demographic differences without recognizing the patterns or the problematic nature of the relative difference for either outcome as a measure of association.

    REFEFENCES

    1. Scanlan JP. Race and mortality revisited. Society 2014;51:327-346
    http://link.springer.com/article/10.1007%2Fs12115-014-9790-1#page-1
    2. Scanlan JP. Measuring health and healthcare disparities. Federal Committee on Statistical Methodology 2013 Research Conference (March 2014)
    http://www.copafs.org/UserFiles/file/fcsm/J4_Scanlan_2013FCSM.pdf
    CONFLICT OF INTEREST: None Reported
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