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\begin{document}

\title{Racial and Ethnic Disparities in Survival of Children with Brain and
Central Nervous Tumors in the United States}



\author[1]{Joseline  Haizel - Cobbina}%
\author[2]{Logan Spector}%
\author[2]{Christopher Moertel}%
\author[2]{Helen Parsons}%
\affil[1]{University of Minnesota School of Public Health}%
\affil[2]{University of Minnesota}%


\vspace{-1em}



  
  \date{May 14, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
BACKGROUND Despite improvements in overall survival for pediatric
cancers, treatment disparities remain for racial/ethnic minorities
compared to non-Hispanic white; however, the impact of race on treatment
outcomes for pediatric brain and central nervous system (CNS) tumors in
the United States is not well known. METHODS We included 8713 children
aged 0 -- 19 years with newly diagnosed primary brain and CNS tumors
between 2000 -- 2015 from the Census Tract-level SES and Rurality
Database developed by Surveillance, Epidemiology and End Results
Program. We used Chi-square tests to assess differences in
sociodemographic, cancer, and treatment characteristics by
race/ethnicity and Kaplan--Meier curves and Cox proportional hazards
models to examine differences in 10-year survival, adjusting for these
characteristics. RESULTS Among 8,713 patients, 56.75\% were non-Hispanic
white, 9.59\% non-Hispanic black, 25.46\% Hispanic, and 8.19\% from
``other'' racial/ethnic groups. Median unadjusted survival for all
pediatric brain tumors was 53 months but varied significantly by
race/ethnicity with a median survival of 62 months for Non-Hispanic
whites, 41 months for Non-Hispanic blacks, and 40 months for Hispanic
and Other. Multivariable analyses demonstrated minority racial groups
still had significantly higher hazard of death than non-Hispanic whites;
Hispanic {[}aHR 1.25 (1.18 - 1.31){]}; non-Hispanic black {[}aHR
1.12(1.04 - 1.21){]}; Other {[}aHR 1.22(1.12 - 1.32){]}. Results were
consistent when stratified by tumor histology. CONCLUSION We identified
disparities in survival among racial/ethnic minorities with pediatric
brain and CNS tumors, with Hispanic patients having the highest risk of
mortality. Eliminating these disparities requires commitment towards
promoting heath equity and personalized cancer treatment.%
\end{abstract}%



\sloppy


\textbf{Racial and Ethnic Disparities in Survival of Children with Brain
and Central Nervous Tumors in the United States}

Joseline Haizel-Cobbina, MD, MPH\textsuperscript{1}; Logan G. Spector,
PhD\textsuperscript{2}; Christopher Moertel, MD\textsuperscript{3};
Helen M. Parsons, PhD, MPH\textsuperscript{1}

1. Division of Health Policy and Management, University of Minnesota,
Minneapolis, MN

2. Division of Pediatric Epidemiology and Clinical Research, University
of Minnesota, Minneapolis, MN

3. Division of Pediatric Hematology and Oncology, University of
Minnesota, Minneapolis, MN

Corresponding Author:

Joseline Haizel-Cobbina, MD, MPH

Division of Health Policy and Management

School of Public Health

University of Minnesota

420 Delaware Street SE

MC 729

Minneapolis, MN 55455

Phone: (952) 492-1075

Fax: (612) 626-6931

Email:

\emph{haize001@umn.edu}

\textbf{Abstract word count:} 250 of 250

\textbf{Manuscript Word Count:} 2995 out of 3,500

\textbf{Number of Figures:} 1

\textbf{Number of Tables:} 3

\textbf{Number of Supplemental Table:} 1

\textbf{Source of Funding:} This work was supported in part by NIH P30
CA77598 Masonic Cancer Center.

\textbf{Running Head:} Racial Disparities in Childhood CNS tumor
Survival

\textbf{Key words:} brain, central nervous system, tumor, race,
ethnicity, survival

Abbreviations\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
SEER & Surveillance Epidemiology and End Results\tabularnewline
\midrule
\endhead
CNS & Central nervous system\tabularnewline
NCI & National Cancer Institute\tabularnewline
(ICD-O-3) & International Classification of Diseases for Oncology, 3rd
Edition\tabularnewline
SES & Socioeconomic Status\tabularnewline
NOS & Not Otherwise Specified\tabularnewline
SAS & Statistical Analysis System\tabularnewline
aHR & Adjusted Hazard Ratio\tabularnewline
\bottomrule
\end{longtable}

\textbf{Data Availability Statement}

The data that support the findings of this study are available from the
Surveillance Epidemiology and End Results Program
(\emph{https://seer.cancer.gov/seerstat/databases/census-tract/index.html})
Restrictions apply to the availability of these data. Data are available
with permission and approval.

\emph{}

\emph{ABSTRACT}

\textbf{BACKGROUND}

Despite improvements in overall survival for pediatric cancers,
treatment disparities remain for racial/ethnic minorities compared to
non-Hispanic white; however, the impact of race on treatment outcomes
for pediatric brain and central nervous system (CNS) tumors in the
United States are not well known.

\textbf{METHODS}

We included 8713 children aged 0 -- 19 years with newly diagnosed
primary brain and CNS tumors between 2000 -- 2015 from the Census
Tract-level SES and Rurality Database developed by Surveillance,
Epidemiology and End Results (SEER) Program. We used Chi-square tests to
assess differences in sociodemographic, cancer, and treatment
characteristics by race/ethnicity and Kaplan--Meier curves and Cox
proportional hazards models to examine differences in 10-year survival,
adjusting for these characteristics.

\textbf{RESULTS}

Among 8,713 patients, 56.75\% were non-Hispanic white, 9.59\%
non-Hispanic black, 25.46\% Hispanic, and 8.19\% from ``other''
racial/ethnic groups. Median unadjusted survival for all pediatric brain
tumors was 53 months but varied significantly by race/ethnicity with a
median survival of 62 months for Non-Hispanic whites, 41 months for
Non-Hispanic blacks, and 40 months for Hispanic and Other. Multivariable
analyses demonstrated minority racial groups still had significantly
higher hazard of death than non-Hispanic whites; Hispanic {[}aHR 1.25
(1.18 - 1.31){]}; non-Hispanic black {[}aHR 1.12(1.04 - 1.21){]}; Other
{[}aHR 1.22(1.12 - 1.32){]}. Results were consistent when stratified by
tumor histology.

\textbf{CONCLUSION}

We identified disparities in survival among racial/ethnic minorities
with pediatric brain and CNS tumors, with Hispanic patients having the
highest risk of mortality. Eliminating these disparities requires
commitment towards promoting heath equity and personalized cancer
treatment.

\emph{INTRODUCTION}

While pediatric cancers represent less than 1\% of the cancer burden in
the United States, cancer remains the major cause of non-injury related
mortality among children.\textsuperscript{1,2,3,4} Brain and central
nervous system (CNS) tumors are the most common type of pediatric cancer
in the US after leukemia and have the highest mortality rates among all
cancers affecting children.\textsuperscript{5,6,7,8,9,10} While the
incidence and mortality of pediatric brain and CNS tumors remains high,
previous research has identified significant differences across racial
and ethnic groups in both diagnosis and treatment in this
population.\textsuperscript{6,11,12} Several studies have identified a
significantly higher incidence of brain and CNS tumors in non-Hispanic
white children relative to those in racial/ethnic
minorites.\textsuperscript{7,8,9,13} While scientific breakthroughs in
cancer treatment have improved cancer survival, leading to a one-third
decrease in overall pediatric cancer mortality from 1990-2016, these
advances have not benefited all racial/ethnic groups
equally.\textsuperscript{1,14} Specifically, despite the observed
improvement in overall survival for pediatric cancers, disparities are
evident in access to and use of guideline-recommended treatment and
outcomes across racial/ethnic groups. \textsuperscript{6,15,16,17} Prior
research has demonstrated that minority populations including African
Americans, American Indian, Native populations, and Hispanics have worse
pediatric cancer survival compared to non-Hispanic
whites.\textsuperscript{7,17,18,19,20,21,} These studies have identified
significant opportunities to reduce racial/ethnic disparities to improve
both detection and survival in pediatric cancer patients.

Prior research also demonstrates significant gaps in our understanding
of racial/ethnic disparities in pediatric brain and CNS tumors. Two
previous studies have shown that socioeconomic status (SES) does not
influence the relationship between race/ethnicity and survival for solid
tumors including pediatric brain and CNS
tumors,\textsuperscript{6,22}but limited work has been done to evaluate
the mechanisms by which race/ethnicity influences survival outcomes
independent of SES. Based on the existing knowledge gap, the purpose of
this study is to explore if racial/ethnic disparities in survival for
pediatric brain and CNS tumors can be partially explained by
sociodemographic and treatment differences across these populations.

\emph{METHODS}

In this retrospective, population-based cohort study, we included
children between the ages of 0-19 years newly diagnosed with primary CNS
tumors between 2000 - 2015 in the Surveillance, Epidemiology, and End
Results (SEER) Program sponsored by the National Cancer Institute (NCI).
These population-based cancer registries include all incident cancer
from 18 geographical locations in the US representing more than 28\% of
the US population.\textsuperscript{23} SEER collects demographic,
clinical, treatment and survival information on all incident cancers
(excluding non-melanoma skin cancer). Tumor histology is classified
using International Classification of Diseases for Oncology (ICD-O-3)
codes.\textsuperscript{24} We additionally received special permission
to access the Specialized Census Tract-level SES and Rurality Database
developed by SEER. In these data, socioeconomic status for patients
represented by Yost quintile reflects the SES group for the patients'
census tract of residence at the time of disease (see below for measure
definition). \textsuperscript{25,26} The SES Yost quintile
classification of census tracts is based on a time dependent composite
score of the social and economic stratification of the area in which a
patient resides at the time of diagnosis.\textsuperscript{26}

Cancers diagnosed only by direct visualization or clinical impression
without any imaging or laboratory confirmation were excluded from the
study (n=73). Cases diagnosed by autopsy or death certificate only were
also excluded (n=41), as were cases without information on their SES
(n=151). Patients who had the optic nerve as the primary site of tumor
were also excluded (n=723) from the data set due to its association with
neurofibromatosis and complex natural history and
therapy.\textsuperscript{27} Our final sample included 8,713 children
aged 0-19 at diagnosis.

Measures

The independent variables measured were age at the time of diagnosis,
race, gender, Yost quintile, stage of cancer at diagnosis, histological
type of tumor, tumor grade, and treatment received: radiotherapy,
chemotherapy, and surgery. Study subjects were categorized into four age
groups: 01-04 years, 05-09 years, 10-14 years, and 15-19 years.
Race/ethnicity was categorized as non-Hispanic white, Hispanic, African
American, with Asian or Pacific Islander/ American Indian/Unknown race
all grouped together as ``Other'' due to the small numbers in these
groups. Yost quintile is categorized into five groups with Group 1
having the lowest SES (\textless{}20th percentile) and Group 5 having
the highest SES (\textgreater{}80th percentile).\textsuperscript{25}

Tumor grade was reclassified as low grade (Well differentiated: Grade I
and Moderately differentiated: Grade II) and high grade (Poorly
differentiated: Grade III and Undifferentiated anaplastic Grade IV)
tumor. Based on the treatment received, chemotherapy and radiotherapy
were simply grouped as ``yes'' and ``no''. Patients were classified as
yes if they received the various types of radiotherapy: beam radiation,
radioactive implants, radioisotopes, combination of beam with implants
or isotopes, or radiation not otherwise specified (NOS). Surgery status
was classified as local excision/excisional biopsy, subtotal tumor
resection, gross total tumor resection, partial lobectomy, total
lobectomy (includes 86 cases who had unspecified surgery), or surgery
not done/unknown.

Due to small sample sizes, histological tumor types were grouped as
diffuse astrocytoma (protoplasma, fibrillary) and mixed glioma,
anaplastic astrocytoma and glioblastoma, pilocytic astrocytoma,
astrocytoma NOS and unique variants, ependymoma/anaplastic
ependymoma/ependymoma variants, embryonal/primitive/medulloblastoma,
glioma NOS.

Our dependent variable was overall survival. Survival was defined as the
time from diagnosis until death of a study subject or the end of the
follow-up period (November 2018).

Statistical Analysis

Chi-square tests were used to assess differences in the independent
variables of interest across the four racial groups. Kaplan-Meier curves
were used to estimate the unadjusted overall survival by race. The log
rank test was used to estimate the differences in survival among the
racial groups. Multivariable Cox proportional hazards models were used
to determine the differences in overall risk of mortality in the study
sample based on the independent variables including race, age at
diagnosis, Yost Quintile, stage, tumor grade, histology, radiation,
chemotherapy, and surgery.. All Chi-square tests and survival analyses
were conducted using SAS version 9.4 statistical software, with p-values
\textless{}0.05 considered significant.

\emph{RESULTS}

We identified 8713 cases newly diagnosed with brain and CNS tumor from
2000-2015. 56.75\% were non-Hispanic whites, 9.59\% were non-Hispanic
black, 25.46\% were Hispanic, and 8.19\% belong to ``Other'' race (Table
1). The majority of cancer diagnoses were children aged 0-4 years
(31.49\%). The age at diagnosis differed significantly by race/ethnicity
(p\textless{}0.0001). 53.81\% of children diagnosed with brain tumor
were males and 46.19\% were females. We identified no significant
differences in the distribution of patients by gender among the four
racial groups (p=0.0660). Yost quintile was significantly different by
race (p\textless{}0.0001). Non-Hispanic blacks had the largest
proportion (35.05\%) belonging to Yost quintile Group 1, with
non-Hispanic whites having the largest proportion (19.82\%) in Group 3,
and Other with the largest proportion (32.07\% ) in Group 5.

Pilocytic astrocytoma was the most common histological type of tumor
(30.08\%) and diffuse astrocytoma (protoplasma, fibrillary). The
histological type of tumor differed significantly by racial group
(p\textless{}.0001). Non-Hispanic Whites had the highest proportion of
pilocytic astrocytoma and diffuse astrocytoma (protoplasma, fibrillary)
and mixed glioma tumor types, Hispanics had the largest proportion of
ependymoma/anaplastic ependymoma/ependymoma variants and
embryonal/primitive/ medulloblastoma tumor types, and non-Hispanic
blacks had the largest proportion of astrocytoma NOS and unique variants
and glioma NOS tumor types.

By tumor stage, the majority (78.56\%) were localized, with a lesser
proportion of tumors being regional (11.61\%), distant (6.09\%), or
unknown/unstaged (3.73\%). The racial groups differed by tumor stage
(p=0.0003). The grade of the majority (68.72\%) of tumors was not
described as CNS tumor grade is inferred by name, 16.93\% of tumors were
described as high grade, and 14.35\%, low grade tumors. Significant
differences (p=0.0043) were also noted across racial/ethnic groups by
tumor grade.

Regarding cancer therapy, among the cases with information on treatment
received, we observed a larger proportion of patients having surgery
(76.85\%) than chemotherapy (41.54\%) or radiation (39.60\%). We noted
significant differences (p\textless{}0.0001) in cancer therapy received
by the racial/ethnic groups for all three treatment modalities.
Hispanics had the largest proportion of patients receiving chemotherapy
or radiation therapy with non-Hispanic whites having large proportions
of patient not receiving chemotherapy or radiation therapy / status
unknown. Non-Hispanic blacks had the largest proportion of patients who
received no form of surgical therapy/ surgery status unknown.

Survival

Plotted survival curves (Figure 1) for pediatric brain tumors showed
disparities in survival across racial/ethnic groups (p\textless{}0.001).
Overall median survival for all pediatric brain and CNS tumors (Fig. 1A)
was 53 months (95\% CI, 50-55). Non-Hispanic whites had better survival
(Fig. 1B) with a median of 62 months (95\% CI, 59-65). The remaining
three racial groups had a worse survival with non-Hispanic blacks having
a median survival of 41 months (95\% CI, 34-47) and Hispanics and
``Other'' racial/ethnic groups both experiencing a median survival of 40
months (Table 2). When stratified by histology, anaplastic astrocytoma
and Glioblastomas had the worst survival (Fig. 1C) with an overall
median survival of 14 months (95\% CI, 13-15). There were statistically
significant differences in survival by race/ethnicity within these
histologic sub-types (p=0.0001) with Hispanics and non-Hispanic blacks
having a worse survival than non-Hispanic whites and Other. Children
diagnosed with diffuse astrocytoma (protoplasma, fibrillary) and Mixed
glioma (Fig. 1D), had a good prognosis with an overall median survival
of 89 months (95\% CI, 80-98) with no statistically significant
differences across racial/ethnic groups (p=0.2908).

Multivariate adjustment of the model also revealed non-Hispanic black
{[}adjusted Hazard Ratio (aHR) 1.12(1.04-1.21){]}, Hispanic {[}aHR 1.25(
1.18- 1.31) {]}, and Other {[}aHR 1.22( 1.12- 1.32){]} racial groups had
a significantly increased hazard of death as compared to non-Hispanic
whites (Table 3). Hispanics and ``Other'' had a slightly increased
hazard of death than was found in the unadjusted model while
non-Hispanic blacks had a significantly decreased 10-year hazard of
death in the adjusted model as compared to the unadjusted model.

There was no statistical difference between each Yost quintile groups
and the reference group with the 10-year hazard of death for each group
being approximately the same as that of the reference group. Controlling
for all other variables decreased the hazard of death associated with
the tumor type except for anaplastic astrocytoma and glioblastoma tumor
types which still had a significantly high hazard of death {[}aHR,
2.13(1.83-2.48){]}.

Sensitivity Analyses

We re-analyzed our survival models evaluating the relationship between
race/ethnicity and survival to evaluate whether the relationship varied
when limited to 5-year hazard of death. The Cox proportional hazard
model to determine the 5-year hazard of death (Supplemental Table S1)
showed only Hispanic patients having a significantly higher hazard of
death than non-Hispanic white patients in both the unadjusted model
(p\textless{}0.0001) and the adjusted model (p=0.0003). To a large
extent, 5- year hazard of death associated with histology type and
surgery modality did not differ significantly within each group while
significant differences were largely noted in the remaining covariates
in both the unadjusted and adjusted models except for hazard of death
associated with radiation, which was also non-significant. Additionally,
we found no significant interaction between race and histology type in
the survival model, indicating there is no differential impact of race
on survival by histology type.

\emph{DISCUSSION}

Overall, non-Hispanic whites had the highest 10-year survival, with
non-Hispanic blacks, Hispanics, and Other having a worse survival.
Considering histologic types, anaplastic astrocytoma and glioblastoma
had the lowest survival and diffuse astrocytoma (protoplasma,
fibrillary) and mixed glioma had the highest survival. This is
consistent with findings from previous
studies.\textsuperscript{8,28,29,30,31,32} This study differs from other
studies of pediatric brain and CNS tumor survival because it assesses
the racial disparities in brain and CNS tumor survival using recent
national specialized census tract data that provide information on both
SES and cancer treatment received by patients.

The largest group of minority patients were Hispanics, which is not
surprising because Hispanics are currently the largest racial minority
and one of the fastest growing racial minority groups in the
US.\textsuperscript{33} Similar to what was found in other
studies\textsuperscript{6,11,12} there was a male predominance in
diagnosed cases and the majority of cases were diagnosed before age ten.
Pilocytic astrocytoma was found to be the most common tumor type in
children, with non-Hispanic whites having the highest proportion of
cases. This concurs with findings from other
studies.\textsuperscript{6,12} It was also previously shown that
non-Hispanic blacks had the highest burden of
medulloblastoma,\textsuperscript{34} however, similar to the findings of
Cooney, et al. and Barnholtz-Sloan et al.,\textsuperscript{7,11} our
study showed Hispanics had the highest burden of both medulloblastoma
and ependymoma. ``Other'' race/ethnicities had the highest proportion of
anaplastic astrocytoma and glioblastoma histology types. Studies that
examined these histologies separately found that non-Hispanic whites had
an increased proportion of glioblastoma tumors\textsuperscript{8} while
non-Hispanic blacks had an increased proportion of anaplastic
astrocytoma.\textsuperscript{11}

Even though our study showed a strong association between race and SES,
similar to Austin and Kehm's findings,\textsuperscript{6,22} SES was not
significantly associated with adverse cancer outcomes in the univariate
and multivariate models for both 5-year and 10-year risk of death.
Accounting for SES in the multivariate model reduced the risk of death
across all racial groups. This supports findings from previous studies
on the relationship between SES and solid tumor outcomes demonstrating
that low SES is not associated with poor survival
outcomes.\textsuperscript{6,22} Results from our study suggest that
factors other than SES mediate the racial survival disparities observed
in brain and CNS tumors.

Examining the multivariate analysis, we found that the 10-year hazard of
death was significantly increased for all three minority racial groups
as compared to non-Hispanic whites, with Hispanics having the highest
risk of death. Survival reaches a plateau for most tumors quite late
with the exception of high-grade gliomas and
medulloblastoma.\textsuperscript{35,36,37} It is thus not surprising
that in our study, the racial/ethnic survival disparities were more
pronounced in the 10-year models. Late mortality could also occur in
5-year survivors, attributable to multiple causes including late
treatment effects, tumor recurrence or progression which could be
influenced by quality of initial therapy.\textsuperscript{38,39,40} It
will be informative to look at the cause-specific mortality for cases.

The relatively poor 5-year survival seen among Hispanics could be due to
multiple factors. Based on the study results, Hispanics have the highest
proportion of patients undergoing partial lobectomy. This procedure was
associated with an increased 5-year risk of death based on the study
results. Similar to finding from other studies\textsuperscript{6,41},
our results showed that Hispanics have a slighter higher burden of cases
reporting with advanced cancer compared to the other racial groups. It
may stem from the fact that the affected individuals may be
uninsured/underinsured which is influenced by several factors including
parents' immigration status and healthy families who choose to forgo
insurance.\textsuperscript{42,43}

In our study, we found significant differences in treatment modality by
race/ethnicity, which may partially explain the increased risk of death
seen in minority racial groups. Similar treatment differences were noted
in a study which addressed the disparities in brain tumor
treatment.\textsuperscript{13} Considering that treatment received is
known to impact survival,\textsuperscript{19} patients who receive
inadequate treatment or poor quality treatment have less chances of
survival. Minority populations as compared to non-Hispanic whites often
receive treatment from low volume hospitals which are less equipped to
handle such cases rather than high volume hospitals or specialized
cancer centers where they can receive adequate and quality care from a
multidisciplinary clinical team for both initial therapy and follow up
care for survivors.\textsuperscript{10,13,38} Furthermore, there is
evidence to suggest that racial discrimination on the part of healthcare
providers, minority patients being less likely to be enrolled in
clinical trials, and patients declining treatment options due to
mistrust of the health system contribute to disparities in
treatment.\textsuperscript{13,20,44,45,46,47,48} There could also be
racial differences in the response to chemotherapeutics due to potential
differences in pharmacogenomics and tumor molecular markers across the
racial/ethnic groups.\textsuperscript{49,50} However, there doesn't
appear to be a documentation of raced-based biological differences in
these factors and the extent to which they impact treatment
outcomes.\textsuperscript{37} Future studies should specifically explore
host and tumor genetic factors and its influence on treatment response
across racial groups.

Challenges with patient provider communication especially when it
involves patients with limited English proficiency (LEP), the majority
of which are from minority racial groups\textsuperscript{51} could
negatively impact delivery of optimum health care, patients' compliance
to therapy, follow up care and ultimately treatment outcomes. Few
studies done to evaluate the impact of language barrier on cancer
treatment outcomes indicate that there is limited information shared
between providers and patients even when interpreters are engaged due to
difficulties in direct communication between the two
parties.\textsuperscript{52,53,54} The impact of patient and provider
communication and the role of medical interpreters in cancer treatment
and outcomes need to be explored further in future studies.

The study has several limitations. Data for this study were obtained
from SEER and the supplementary Specialized Census Tract-level SES and
Rurality Database which provides information on the overall SES of the
census tract of residence of a patient and not the SES of the
patient.\textsuperscript{25,26} Only information on the insurance status
of patients diagnosed from 2007 -- 2015 was available, hence the
influence of insurance on treatment outcome was not assessed in this
study. Additionally, Asians, American Indians, and cases without racial
identity were grouped together due to their small sample sizes, which
does not allow for good representation of the independent survival
outcomes of Asians and American Indians. Treatment information in SEER
is incomplete with no clear differentiation between cases who did not
receive treatment and those whose treatment information is missing,
making it difficult to infer real differences in treatment among the
racial groups. SEER does not have information on molecular tumor markers
or genomic ancestry which may influence the racial disparities in
outcome.\textsuperscript{55,56,57} Finally, the data do not include
patients' choice in the treatment.

\emph{CONCLUSION}

Overall, we identify significant racial/ethnic disparities in survival
among those diagnosed with pediatric brain and CNS tumors, with Hispanic
patients having the highest risk of mortality, even after accounting for
stage of diagnosis, tumor grade, and SES. The observed differences in
survival become more pronounced with increasing follow up time.
Eliminating these disparities requires commitment towards promoting
equity in healthcare delivery. Future studies aimed at delineating how
differences in host and tumor genetic factors impact treatment response
could help optimize treatment for patients including offering
personalized cancer treatment.

\textbf{CONFLICTS OF INTEREST} :

There are no financial disclosures or conflicts of interest to report.

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\emph{FIGURE LEGEND}

Figure 1. Kaplan--Meier survival curves for children diagnosed with
pediatric primary brain and CNS tumor 2000-2015.

Figure 1A. Kaplan Meier curve for overall 10-year tumor survival

Figure 1B. Kaplan Meier curve for 10-year tumor survival by race

Figure 1C. Kaplan Meier curve for 10-year survival by race for
Anaplastic astrocytoma and Glioblastoma histology group

Figure 1D. Kaplan Meier curve for 10-year survival by race for Diffuse
astrocytoma (protoplasma, fibrillary) and Mixed glioma histology group.

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