Socioeconomic disparities in survival after high-risk neuroblastoma
treatment with modern therapy
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 sought to examine the relationship
between socioeconomic status (SES) and OS in children with high-risk
neuroblastoma, and to investigate 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
1991-2015 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 sub-cohort 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≤0.1) in univariate and bivariate modeling with treatment era.
Results: Among 1,217 children, 2-year OS improved from 53.0±3.4% in
1991-1998 to 76.9±2.9% in 2011-2015 (p<0.001). In univariate
analyses, children with Medicaid (hazard ratio [HR]=1.40, 95%
confidence interval [CI]=1.05-1.86, p=0.02) and those in
high-poverty counties (HR=1.74, CI=1.17-2.60, p=0.007) experienced an
increased hazard of death. No interactions between treatment era and SES
variables were statistically significant in multivariable analyses,
indicating that changes in OS over time did not differ between groups.
Conclusions: Low SES is associated with inferior survival in children
with high-risk neuroblastoma. Survival disparities have not widened over
time, suggesting equitable access to and benefit from therapeutic
advances. Interventions to narrow existing disparities are paramount.