Access to Care

Access to care, particularly specialty care, is associated with outcomes. For example, children who received treatment at a specialty cancer center, such as a comprehensive cancer center or a site that is part of the Children’s Oncology Group,  experienced better survival rates compared with children who received care elsewhere (HR, 1.9; 95% CI, 1.2-1.8).4

However, the cost of cancer treatment or accessing specialty care may serve as a barrier for some families. Therefore, parents of a higher socioeconomic status or with a higher income — which is potentially the result of a higher education level — are more likely to access treatment. For example, Black children with acute lymphoblastic leukemia (ALL) have higher rates of relapse compared with White children.5 Yet, this difference in relapse rate was not observed at St. Jude Children’s Research Hospital, a care setting that eliminates out-of-pocket costs for treatment.

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In the United States, access to care is often related to insurance status. A population study of more than 66,000 adolescents and young adults with cancer found that lack of insurance in the United States was significantly associated with an increased risk of mortality from cancer.6 Older patients in the young adult group had the greatest risk. In addition, lack of insurance was also associated with an increased likelihood of presenting with metastatic disease.

Also tied to socioeconomic status is race and ethnicity.  Racial/ethnic disparities in medicine in the United States is well known, and pediatric cancer outcomes are no different.1 Multiple studies demonstrate that children with cancer, particularly ALL, who are Black, Hispanic, Native American, or of Vietnamese descent had lower survival rates compared with non-Hispanic White individuals. For example, a retrospective cohort study of more than 67,000 pediatric patients with cancer evaluated the role of race and ethnicity and cancer-related mortality.7 Compared with cancers that are generally not amenable to treatment, patients with typically treatable cancers had an increased risk of mortality if they were non-Hispanic Black (HR, 1.59; 95% CI, 1.41-1.80) or Hispanic (HR, 1.63; 95% CI, 1.50-1.78).

This study did not evaluate potential reasons for this disparity, but postulated that it could be due to multiple factors such as adherence to treatment, differences in disease characteristics, pharmacogenetics, and socioeconomic status. However, socioeconomic status is likely to play a major role, as there was no significant difference in survival among Black and White children with cancer at St. Jude,8 suggesting that access to care affects mortality rates.1


Although the treatment of most pediatric cancers has improved, thereby improving outcomes, disparities in outcomes remain across socioeconomic statuses and racial/ethnic backgrounds. Access to care is critical for improved outcomes, and access is generally improved among families with higher education level and higher disposable income.


  1. Winestone LE, Aplenc R. Disparities in survival and health outcomes in childhood leukemia. Curr Hematologic Malig Rep. 2019;14:179-186. doi:10.1007/s11899-019-00515-x
  2. Alicandro G, Bertuccio P, Sebastiani G, La Vecchia C, Frova L. Parental education and cancer mortality in children, adolescents, and young adults: a case-cohort study within the 2011 Italian Census Cohort. Cancer. Published August 18, 2020. doi:10.1002/cncr.33146
  3. Tolkkinen A, Madanat-Harjuoja L, Taskinen M, et al. Impact of parental socioeconomic factors on childhood cancer mortality: a population-based registry study. Acta Oncologica. 2018;57:1547-1555. doi:10.1080/0284186X.2018.1478125
  4. Wolfson J, Sun C-L, Wyatt L, Stock W, Bhatia S. Adolescents and young adults with acute lymphoblastic leukemia and acute myeloid leukemia: impact of Care at Specialized Cancer Centers on survival outcome. Cancer Epidemiol Biomark Prev. 2017;26(3):312-320. doi:10.1158/1055-9965.EPI-16-0722
  5. Burke W, Thummel K. Precision medicine and health disparities: the case of pediatric acute lymphoblastic leukemia. Nurs Outlook. 2019;67(4):331-336. doi:10.1016/j.outlook.2019.05.003
  6. Colton MD, Goulding D, Beltrami A, et al. A U.S. population‐based study of insurance disparities in cancer survival among adolescents and young adults. Cancer Med. 2019;8:4867-4874. doi:10.1002/cam4.2230
  7. Delavar A, Barnes JM, Wang X, Johnson KJ. Associations between race/ethnicity and US childhood and adolescent cancer survival by treatment amenability. JAMA Pediatrics. 2020;174:428-436. doi:10.1001/jamapediatrics.2019.6074
  8. Pui CH, Pei D, Pappo AS, Howard SC, Cheng C, Sandlund JT, et al. Treatment outcomes in black and white children with cancer: results from the SEER database and St Jude Children’s Research Hospital, 1992 through 2007. J Clin Oncol. 2012;30(16):2005-2012. doi:10.1200/JCO.2011.40.8617