Subspecialty pediatrics have lagged behind primary care pediatrics in recognizing adverse social determinants of health (SDOH) as salient to outcomes, key drivers of inequity, and worthy of systematic investigation.1 A population frequently hospitalized with chronic illness with well-defined inequities is children with cancer. More than 1 in 5 pediatric oncology families report low-income, and at least 1 household material hardship (HMH; food, housing, or utility insecurity) at diagnosis.2 Identifying whether children from marginalized racial/ethnic groups are disproportionately exposed to poverty, a modifiable SDOH, can inform intervention opportunities for children with chronic illness to mitigate disparities.3 We leveraged parent-reported poverty data collected as a prospective aim of a clinical trial for children with newly diagnosed acute lymphoblastic leukemia (ALL) to characterize modifiable poverty exposures by race/ethnicity.
Methods
The Dana Farber Cancer Institute ALL Consortium phase III randomized clinical trial 16-001 (NCT03020030) enrolled children aged 1 to 21 years with de novo ALL from 2016 to 2022 at 8 US and Canadian centers. It included an embedded prospective cohort study evaluating parent-reported SDOH via survey within 32 days of enrollment.4,5 The study was approved by enrolling sites’ institutional review boards.
Child’s parent-reported race and ethnicity were collected using US and Canadian federal reporting guidelines and combined to reflect populations per best practice (Supplemental Table 1). HMH was defined as at least 1 of 3 resource insecurities (housing, food, or utilities) using a standardized instrument,5 and additionally examined as ordinal number of unmet resource needs (0–3). Low income was defined as annual household income <200% US Federal Poverty Level for subject year of enrollment.6 To allow comparison across the trial cohort, Canadian to US dollar conversion was calculated via the July 2022 exchange rate of 1 CAD to 0.7765 USD.7 Comparisons were made using the χ2 test or Fisher exact test, as appropriate. Analyses were performed using SAS, version 9.
Results
The analytic cohort included 375 subjects, including 247 (66%) treated at US sites and 128 (34%) at Canadian sites. Parent-reported race/ethnicity and poverty exposures are displayed in Supplemental Table 2.
One hundred and twenty (32%) families reported HMH at diagnosis, including 47% (n = 17) of Black families (P < .001) and 68% (n = 45) of Hispanic families (P < .001) vs 19% (n = 46) of non-Hispanic White (NHW) families (Fig 1). Housing insecurity was present in 33% (n = 12) of Black families (P < .001) and 47% (n = 31) of Hispanic families (P < .001) vs 11% (n = 26) of NHW families. Many Black and Hispanic families reported more than 1 resource insecurity; specifically, 8% (n = 3) of Black families (P = .10) and 14% (n = 9) of Hispanic families (P = .001) vs 3% (n = 6) of NHW families reported 3 HMH domains.
Poverty exposures by race/ethnicity in a clinical trial for children with newly diagnosed acute lymphoblastic leukemia. HMH, household material hardship (housing, food, and/or utilities insecurity); low income, household income <200% Federal Poverty Level.
Poverty exposures by race/ethnicity in a clinical trial for children with newly diagnosed acute lymphoblastic leukemia. HMH, household material hardship (housing, food, and/or utilities insecurity); low income, household income <200% Federal Poverty Level.
Among 336 (89%) families with available income data, 131 (39%) reported low income, including 52% (14/27) of Black families and 74% (40/54) of Hispanic families vs 27% (62/226) of NHW families (P = .009 and <.001, respectively).
Overall, among 179 families who reported any poverty exposures, 40% (n = 72) reported both low-income and HMH poverty exposures (Fig 2).
Distribution of discrete (low-income or HMH) and overlapping (both low income and HMH) poverty exposures among the n = 179 children with ALL whose families report poverty exposure at time of clinical trial enrollment. n = 336/375 families provided complete income and HMH data for analysis, of whom n = 179 reported at least 1 poverty exposure. HMH, household material hardship; low income, household income <200% of the federal poverty level.
Distribution of discrete (low-income or HMH) and overlapping (both low income and HMH) poverty exposures among the n = 179 children with ALL whose families report poverty exposure at time of clinical trial enrollment. n = 336/375 families provided complete income and HMH data for analysis, of whom n = 179 reported at least 1 poverty exposure. HMH, household material hardship; low income, household income <200% of the federal poverty level.
Discussion
In a subspecialty pediatric patient cohort, we demonstrate that Black and Hispanic children with ALL experience high frequencies of modifiable poverty exposures at diagnosis. Implications of these poverty exposures include differential health care access and inferior disease outcomes—including higher rates of relapse and death.2 These data identify actionable risk exposures disproportionately experienced by marginalized children with complex chronic illness. They provide immediate opportunities for subspecialist and hospital-based pediatric providers to address disparities rooted in systemic racism.
In this cohort, HMH and income poverty distinguished overlapping but nonidentical populations (Fig 2),8 identifying opportunities for exposure-specific (income vs resource poverty) interventions. For example, children living in low-income households may benefit from guaranteed income pilots or interventions to increase means-tested governmental program participation,9 whereas those facing resource insecurities absent low income may require direct resource provision—such as food or transportation vouchers—during cancer treatment.10 Cancer-specific interventions targeting both are currently in development (NCT03638453).
Our data are limited by a geographically restricted cohort, with underrepresentation of racial/ethnic identities. Merging of US and Canadian racial/ethnic groups risks misclassification. Replication of these data using larger, more diverse cohorts is ongoing in the Children’s Oncology Group (NCT03914625, NCT03126916).
These data identify marked inequities in modifiable SDOH experienced by marginalized populations within a paradigmatic subspecialty population requiring frequent hospitalization. They provide immediate targets for interventions aimed at addressing racial/ethnic outcome disparities applicable to pediatric populations with complex chronic illness.
This trial has been registered at www.clinicaltrials.gov (identifier NCT03020030).
Dr Karvonen conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript; Drs Umarieyta, Aziz-Bose, Ilcisin, Wolfe, and Rosenberg made substantial contributions to the analysis and interpretation of the data and critically reviewed and revised the manuscript; Drs Koch, Cole, Gennarini, Kahn, Kelly, Tran, Michon, Welch, and Silverman made substantial contributions to the acquisition of the data at participating sites and critically reviewed and revised the manuscript; Ms Flamand performed statistical analysis and aided Dr Karvonen in table and figure generation, and critically reviewed and revised the manuscript; Ms Valenzuela served as research coordinator and was principally involved in acquisition of data, coordination, and supervision of data, and critically reviewed and revised the manuscript; Dr Bona substantially contributed to study conception and design, acquisition of data, analysis, and interpretation of data; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: National Institutes of Health T32 institutional grant (T32CA009351) and National Cancer Institute (K07CA211847).The National Institutes of Health and National Cancer Institute had no role in the design and conduct of the study
CONFLICTS OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
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