Race/Ethnicity and Poverty Are Associated With Worse Outcomes Among Children With High-Risk Neuroblastoma

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Prior studies by the Children’s Oncology Group (COG) have demonstrated population-based disparities in late relapse rates among Black children with high-risk neuroblastoma, and trial-based disparities in relapse and survival among children living in poverty receiving postconsolidation immunotherapy. But it is unknown whether these disparities persist in upfront clinical trials for newly diagnosed patients.

In a retrospective study investigating race, ethnicity, and socioeconomic disparities in children with high-risk neuroblastoma, researchers found that despite uniform planned treatment for children diagnosed with the cancer enrolled in COG clinical trials, children from marginalized racial/ethnic groups and those living in poverty were more likely to have inferior 5-year overall survival. More studies are needed to determine the mechanisms driving this disparity, including disparate early-phase trial enrollment to inform targeted health equity interventions to improve outcomes in these patients, according to the study authors. The study by Umaretiya et al will be presented during the 2022 ASCO Annual Meeting (Abstract 10005).

Study Methodology

The researchers analyzed data from 696 children enrolled in upfront COG high-risk neuroblastoma clinical trials ANBL0532, ANBL09P1, and ANBL12P1.

Race and ethnicity were the primary exposures categorized as: Black non-Hispanic; Hispanic; other non-Hispanic; or White non-Hispanic. Among the trial participants, 16% of patients were Black non-Hispanic; 11% were Hispanic; 4% were other non-Hispanic; and 69% were White non-Hispanic.

Poverty was the secondary exposure, defined as household (public insurance only vs others); area (census-defined high-poverty ZIP code with > 20% of population living below 100% of the federal poverty level vs < 20% below 100% of the federal poverty level), and rural (census-defined rurality measures linked to ZIP code).

Overall and event-free survival from time of trial enrollment were plotted by Kaplan-Meier methods; associations with race/ethnicity and poverty were evaluated by log-rank tests.


The researchers found that one-third of the children (33%) were household poverty-exposed; 26% were area poverty-exposed; and 15% were rural-exposed. Tumor stage and biology did not differ by race/ethnicity or poverty measures. Five-year overall survival differed significantly by race/ethnicity (47% for Hispanic patients vs 50% for other non-Hispanic vs 61% for White non-Hispanic vs 62% Black non-Hispanic; P = .047). Five-year overall survival was inferior among children exposed to household poverty (53% vs 63%, P = .036) and neighborhood poverty (54% vs 62%, P = .050) compared to unexposed children.

There was no difference in overall survival by rurality. Similar directionality in 5-year event-free survival outcomes by race/ethnicity and poverty were observed without statistical significance.

“Race/ethnicity and poverty exposure are associated with inferior overall survival outcomes among children with high-risk neuroblastoma, despite uniform planned treatment on upfront COG trials. Investigation of mechanisms driving these disparities, including disparate early-phase trial enrollment, are ongoing to inform targeted health equity interventions to improve outcomes,” concluded the study authors.

This study suggests that simply having access to clinical trials does not ensure equitable outcomes by race and ethnicity. These results will allow researchers to develop and focus on new ways to provide care in clinical trials to improve equity.

ASCO Perspective

“These findings in high-risk neuroblastoma point out that while there is an urgent need for all patients to have equal access to the latest cancer treatments, with the goal of improving treatment outcomes in pediatric clinical trials, there remains an effect of poverty on treatment outcomes that persists even when patients are enrolled in a trial and treatment is standardized,” said ASCO President Everett E. Vokes, MD, FASCO, in a statement.

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