Economic Hardship May Be Predictive of Neurocognitive Outcomes in Pediatric Patients Undergoing Radiation Therapy

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Researchers have found that pediatric patients with cancer undergoing radiation therapy may experience greater baseline and long-term neurocognitive outcomes when they have supportive environments compared with those who live in neighborhoods with economic hardship, according to a new study published by Mule’ et al in Neuro-Oncology. The findings suggested that policies and resources providing support at a neighborhood level may help protect high-risk pediatric patients with brain tumors from neurocognitive decline.

“At the simplest level, we found [that] a patient’s environment matters,” explained senior study author Heather Conklin, PhD, Chief of the Section of Neuropsychology in the Department of Psychology and Behavioral Sciences at St. Jude Children’s Research Hospital. “It's not just the diagnosis or treatment the patient receives. It's also the family, neighborhood, and support they can access that predicts [neuro]cognitive outcomes,” she added.


Using a framework called the economic hardship index may allow researchers to account for the environment surrounding the patients. The data collected from the index—including factors such as unemployment, dependency, education, income, crowded housing, and poverty—is presented at the Census block level, comprising groups of 250 and 550 housing units for almost every neighborhood in the United States.

“This is the first time [researchers] in the oncology space [have] used a neighborhood-level variable rather than a family specific measure to predict [neuro]cognitive outcomes in [pediatric patients] treated for brain tumors,” Dr. Conklin highlighted. “The reason that's important is that it gives us more nuanced information about the context in which the [patients are] living. It also opens new areas where we can develop interventions to improve [neuro]cognitive outcomes,” she emphasized.

Study Methods and Preliminary Findings

In the new study, the researchers used the economic hardship index to evaluate how a patient’s neighborhood could correlate with neurocognitive outcomes—and found that those who began treatment with lower neurocognitive abilities as well as those who experienced greater neurocognitive declines following treatment, especially regarding math skills, scored higher on the economic hardship index.

The researchers noted that the predictive power of the economic hardship index may have rivaled that of already known risk factors for neurocognitive decline in these pediatric patients.

“Economic hardship at the neighborhood level predicted how these patients performed cognitively at baseline…and then also based on what [economic hardship index] quartile they were [in], how much they declined or stayed stable over time,” Dr. Conklin detailed. “The gaps that were present prior to treatment widened over time and had more of a relative impact than the well-established clinical factors, such as age at radiation therapy,” she revealed.

The new study followed a growing body of research showing that lower socioeconomic status can predict worse neurocognitive outcomes in pediatric patients with brain tumors who are undergoing radiation therapy. Because the patients involved in the study all received similar care at no expense, the researchers deduced that at least some of the differences in outcomes were likely due to nontreatment-related factors such as living in a high poverty area. Within the overall economic hardship index score components, the factor that most correlated with poor outcomes was neighborhood-level poverty.

“Even though St. Jude is at the forefront of pediatric brain tumor care, there are still challenges for our patients. St. Jude patients receive physical, occupational, and speech therapy while they're here, but they still go back home to their neighborhoods that maybe are higher in crime, have poorer schools, or are overcrowded. They may not have access to the same level of resources once their treatment concludes and they return to their community,” Dr. Conklin indicated.

Therefore, the researchers suggested that environmental conditions in high poverty areas, not individual choice, may have a strong effect on long-term neurocognitive outcomes. As a result, patients may be likely to benefit if physicians and policymakers offer solutions that address these factors for current and future pediatric patients with brain tumors.


While the researchers demonstrated that the economic hardship index can be used to predict poor neurocognitive outcomes beyond traditional treatment and clinical risk factors, they noted that it may not be ready for widespread clinical adoption. Further, there may still be more to learn about the drivers of neurocognitive differences in pediatric patients with cancer. Therefore, they recommended that clinicians be sensitive and resourceful when trying to help the parents of patients who live in areas of high economic hardship proactively protect their child’s neurocognitive health.

“[A]s a clinician, I have to think about how I bring this to [the] families. Clinicians need to learn how to talk effectively to [them] about factors related to economic hardship. We should be thinking creatively about how to help [the] families we know are in a riskier category,” Dr. Conklin stressed. “For example, we can suggest enriching activities that may fit with [the] caregiver’s schedule and resources to help prevent [neuro]cognitive decline like going to parks, going to libraries, and reading regularly at home. [T]hese activities need to be things [the] families can do that are free, don't require them to take off from work, and allow single parents of multiple kids to figure out how to work this into their lifestyle,” she underscored.

The researchers concluded that some of these social or policy interventions may help. Patients with low economic hardship index scores—those from neighborhoods of higher socioeconomic status—may have had better baseline and long-term neurocognitive outcomes. By increasing access to the resources available to families from lower socioeconomic status, clinicians and policymakers may be able to be better protect against neurocognitive decline in pediatric patients treated with radiation therapy for brain tumors

Disclosure: The research in this study was supported by grants from the National Cancer Institute and the American Lebanese Syrian Associated Charities. For full disclosures of the study authors, visit

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.