Socioeconomic inequalities in cancer survival and access to health care among children and adolescents in China, 2018-24: a prospective nationwide cohort study.
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BACKGROUND: To improve health equity, as a Sustainable Development Goal, timely evaluation of inequalities in cancer survival is essential. We aimed to assess the latest nationwide 5-year survival for childhood and adolescent cancers in China and disparities in survival, especially those associated with health-care access. METHODS: Using data from the National Center for Pediatric Cancer Surveillance (covering 1388 surveillance sites and 82·3% of new cases in China), we applied the Kaplan-Meier method to estimate 5-year observed survival for 95 189 cases in patients aged 0-19 years who were diagnosed with cancer between 2018 and 2020. We assessed survival by age group, sex, cancer type (based on the International Classification of Childhood Cancer, third edition), regional Socio-demographic Index (SDI) category, and whether patients were treated within (intraprovincial) or outside (interprovincial) their province of residence. We categorised the 31 provinces into four regions according to the distribution of their SDI scores, a composite metric reflecting overall regional socioeconomic development. We examined survival disparities across regional SDI categories and within each region. We used the densities of seven health-care provision indicators (per 1000 children and adolescents) as proxies for health-care accessibility. We applied random survival forest models to estimate potential reductions in mortality risk among intraprovincial patients under simulated scenarios, where provincial-level indicator densities were set to the highest levels observed either nationally or within their respective regional SDI categories, relative to their actual values. FINDINGS: The 5-year survival of patients with cancer was 77·8% (95% CI 77·4-78·1) among children aged 0-14 years and 75·3% (74·7-75·9) among adolescents aged 15-19 years, with an overall 5-year survival of 77·2% (76·9-77·5) in the entire cohort. Survival was higher in girls (79·0% [78·6-79·4]) than in boys (75·8% [75·4-76·2]). Among the 12 main cancer groups, retinoblastoma had the highest survival (91·2% [90·0-92·3]), whereas malignant bone tumours had the lowest (60·4% [59·0-61·9]). For all cancers combined, survival ranged from 72·6% (71·8-73·4) in low SDI regions to 84·9% (83·8-86·1) in high SDI regions, indicating significantly higher survival in regions with higher socioeconomic status (p<0·0001 for trend). This absolute survival difference between the high and low SDI regions was more pronounced in adolescents (13·4% [13·3-13·5]) than in children (11·7% [11·7-11·8]). Notably, within-region survival disparities existed in each regional SDI category and were most marked in low SDI regions, with provincial 5-year survival ranging from 61·4% to 81·1% (hazard ratio [HR] 2·68 [95% CI 1·99-3·62] for mortality risk). Compared with intraprovincial patients (n=72 867; 5-year survival 76·4% [76·0-76·7]), interprovincial patients (n=22 322) had a significantly higher survival (79·9% [79·3-80·4]; HR 0·81 [0·78-0·84]). Higher socioeconomic areas had greater densities of health-care provision indicators for diagnosis and treatment. Based on scenario-based simulations, the key indicators associated with estimated reductions in mortality risk varied by region, but included the density of the pathology workforce and institutions providing surgery, radiotherapy, and post-treatment supportive care for paediatric cancer. INTERPRETATION: China has achieved major progress in childhood cancer survival, but inequalities remain across and within regions at different levels of socioeconomic development. The level of inequality appears greater among adolescents. While interprovincial health-care seeking was generally associated with higher survival, disparities in outcomes persisted, aligned with the socioeconomic development of patients' residence and treatment locations. Tiered resource allocation for paediatric cancer care at provincial and regional levels should be prioritised in China's health system to advance health equity. FUNDING: National Natural Science Foundation of China, Beijing Research Ward Excellence Program, Beijing Natural Science Foundation, Wu Jieping Medical Foundation, the Cultivation of Pharmaceutical Innovation Varieties and Platforms of Beijing Municipal Science and Technology Commission, and Zhongguancun Administrative Committee.