Persistent Child Poverty and Mortality in a Cohort of Children with Cancer in Alabama

Background: One-fifth of U.S. counties are designated persistent child poverty counties (≥20% of children in poverty since 1980). The association between a persistent child poverty environment and mortality in children with cancer is unknown.

Methods: Our cohort includes 2,089 children with cancer (2000-2016) in Alabama. We used multivariable Cox proportional hazards modeling (adjusted for sociodemographics/clinical characteristics) to assess mortality by persistent child poverty designation at 1, 5, and 10 years from diagnosis. Distance to treatment was subsequently explored.

Results: Forty-two percent of the cohort lived in a persistent child poverty county; they were more likely to be African American (P < 0.0001), have public/no insurance (P = 0.0009), and live >100 miles to treatment (P < 0.0001). Children in persistent child poverty counties were 30% more likely to die by 5 years [95% confidence interval (CI) = 1.06-1.59; P = 0.012]. Distance (per 20-mile increase) to treatment was associated with a 9% increased mortality risk (P < 0.0001). Children with both exposures (distance >100 miles and persistent child poverty) faced the highest mortality risk at 5 years (HR = 1.80; 95% CI = 1.39-2.33; P < 0.0001). In subanalysis, children exposed to persistent child poverty were at higher risk for cancer-related mortality. However, the risk of health-related mortality did not differ.

Conclusions: Among children with cancer from the Deep South, persistent child poverty was a prevalent exposure associated with inferior overall survival. Distance to treatment was independently associated with inferior survival. Children with both exposures had the highest risk of mortality.

Impact: Persistent child poverty is associated with inferior survival among children with cancer; mechanisms underlying this disparity warrant investigation. See related commentary by Orjuela-Grimm and Beauchemin, p. 295.