Investigators have found that socioeconomic deprivation, the presence of modifiable chronic health conditions, and frailty may all independently be associated with increased rates of late mortality among pediatric cancer survivors, according to a new study published by Ehrhardt et al in JAMA Network Open. The findings demonstrated that treating chronic health conditions alone may be inadequate to improve survivors’ life spans without policies to improve local environments.
Study Methods and Findings
“The new discovery was the relationship between social determinants of health at the regional level and increased mortality,” explained corresponding study author Matthew Ehrhardt, MD, MS, Associate Member in the Departments of Oncology, and Epidemiology and Cancer Control at the St. Jude Children’s Research Hospital. “Living in census blocks with high deprivation was associated with increased mortality rates for [pediatric] cancer survivors.”
After using the area deprivation index—measuring the general housing quality, education level, employment status, and poverty levels of a census block containing 600 to 1,000 individuals—to uncover the association between resource deprivation and increased mortality rates, the investigators found that pediatric cancer survivors living in the most resource-deprived localities had a five- to eightfold greater risk of mortality compared to survivors based in localities with the least deprivation.
Even though treatments exist for modifiable chronic health conditions—ranked in increasing severity from grades 1 to 4—they can be difficult to access. The investigators found that pediatric cancer survivors still experienced a two- to fourfold greater risk of mortality compared with the risk found among community controls.
“We found that having both a greater number of modifiable chronic health conditions and conditions of higher severity was associated with a higher risk of mortality in [pediatric cancer] survivors,” Dr. Ehrhardt stressed.
The investigators noted that increases in mortality rates associated with poor local socioeconomic conditions were statistically independent from the risk associated with modifiable chronic health conditions. They further illustrated that living in an impoverished area and having untreated chronic health conditions, especially severe ones, may multiply a pediatric cancer survivor’s risk of mortality.
Conclusions
The association between increased mortality rates and modifiable chronic health conditions emphasized the importance of ensuring that pediatric cancer survivors have access to interventions that may improve these health conditions and subsequently reduce their mortality risk. Separately, the impact of poverty on mortality rates suggested that the local environment may influence mortality beyond the lack of access to specific treatments.
“The biggest take-home [message from these findings] is that when we develop interventions, we need to account for not only the intervention itself, but the supporting factors that help with the delivery and effectiveness of the intervention,” Dr. Ehrhardt underscored. He indicated: “In this case, we show some evidence that those environmental factors included in the [area deprivation index] are important contributors to risk that need to be considered.”
The study also had a direct implication for clinical care—calling special attention to the ways in which clinicians interact with their patients.
“It is important for clinicians to ask patients about their specific situation,” urged Dr. Ehrhardt. “It's easy to prescribe medications or to tell people to exercise; it takes more time and more thoughtfulness to sit and understand environments in which they are residing. As clinicians, we may have limited ability to modify some of those factors. But we can work closely with the rest of the health-care team—such as social workers, for example—to help [pediatric cancer] survivors to identify and access local resources,” he concluded.
Disclosure: The research in this study was supported by grants from the National Institutes of Health (NIH), the NIH Cancer Center Support program, and the American Lebanese Syrian Associated Charities. For full disclosures of the study authors, visit jamanetwork.com.
