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J Adolesc Young Adult Oncol. 2017 Mar;6(1):74-82. doi: 10.1089/jayao.2016.0016. Epub 2016 Oct 18.

Effect of Population Socioeconomic and Health System Factors on Medical Care of Childhood Cancer Survivors: A Report from the Childhood Cancer Survivor Study.

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1 University of Utah School of Medicine , Salt Lake City, Utah.
2 St. Jude Children's Research Hospital , Memphis, Tennessee.
3 Department of Medicine, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania.
4 The Hospital for Sick Children , Toronto, Canada .
5 Fred Hutchison Cancer Research Center , Seattle, Washington.
6 Memorial Sloan Kettering Cancer Center , New York, New York.



To determine the independent contribution of population socioeconomic and health system factors on childhood cancer survivors' medical care and screening.


7899 childhood cancer survivors in the United States and Canada enrolled in the Childhood Cancer Survivor Study (CCSS). Population-level factors were derived from U.S. Area Health Resource File or 201 Canadian Census. Health service utilization and individual-level factors were self-reported. Multivariable logistic regression was used to calculate the effect of population factors on medical care (any care vs. no care; risk-based care vs. general care) and indicated echocardiogram or mammogram, adjusting for individual sociodemographic and health status.


After adjusting for individual factors, population factors had a nominal impact on childhood cancer survivors' medical care and screening. Higher population median income was associated with risk-based survivor-focused care versus general care (odds ratio [OR] 1.05, 95% confidence interval [CI], 1.01-1.09) among all participants, but not among U.S. residents only (OR 1.03, 95% CI, 0.99-1.07). For U.S. residents, the number of CCSS centers within the geographic area was associated with greater odds of receiving risk-based survivor-focused medical care (OR 1.12, 95% CI, 1.04-1.20). Areas with higher median income had higher rates of echocardiogram screening among survivors at risk of cardiomyopathy (for every $10,000 increase in median income, there is a 12% increase in odds of echocardiogram screening; 95% CI 1.05-1.20). A positive relationship was identified between greater number of physicians and surgeons in the county of residence and recommended echocardiogram (for every additional 1000 physicians and surgeons: OR 1.12, 95% CI, 1.01-1.23). We found no association between population-level factors and mammography screening.


Population socioeconomic disparities moderately affect childhood cancer survivors' risk-based medical care and screening after accounting for individual sociodemographic and health factors.


childhood cancer survivor; health disparities; population-level factors; screening; socioeconomic status

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