To improve health equity, as a Sustainable Development Goal, timely evaluation of inequalities in cancer survival is essential. We aimed to assess the latest nationwide 5-year survival for childhood and adolescent cancers in China and disparities in survival, especially those associated with health-care access.
Using data from the National Center for Pediatric Cancer Surveillance (covering 1388 surveillance sites and 82·3% of new cases in China), we applied the Kaplan–Meier method to estimate 5-year observed survival for 95 189 cases in patients aged 0–19 years who were diagnosed with cancer between 2018 and 2020. We assessed survival by age group, sex, cancer type (based on the International Classification of Childhood Cancer, third edition), regional Socio-demographic Index (SDI) category, and whether patients were treated within (intraprovincial) or outside (interprovincial) their province of residence. We categorised the 31 provinces into four regions according to the distribution of their SDI scores, a composite metric reflecting overall regional socioeconomic development. We examined survival disparities across regional SDI categories and within each region. We used the densities of seven health-care provision indicators (per 1000 children and adolescents) as proxies for health-care accessibility. We applied random survival forest models to estimate potential reductions in mortality risk among intraprovincial patients under simulated scenarios, where provincial-level indicator densities were set to the highest levels observed either nationally or within their respective regional SDI categories, relative to their actual values.
The 5-year survival of patients with cancer was 77·8% (95% CI 77·4–78·1) among children aged 0–14 years and 75·3% (74·7–75·9) among adolescents aged 15–19 years, with an overall 5-year survival of 77·2% (76·9–77·5) in the entire cohort. Survival was higher in girls (79·0% [78·6–79·4]) than in boys (75·8% [75·4–76·2]). Among the 12 main cancer groups, retinoblastoma had the highest survival (91·2% [90·0–92·3]), whereas malignant bone tumours had the lowest (60·4% [59·0–61·9]). For all cancers combined, survival ranged from 72·6% (71·8–73·4) in low SDI regions to 84·9% (83·8–86·1) in high SDI regions, indicating significantly higher survival in regions with higher socioeconomic status (p<0·0001 for trend). This absolute survival difference between the high and low SDI regions was more pronounced in adolescents (13·4% [13·3–13·5]) than in children (11·7% [11·7–11·8]). Notably, within-region survival disparities existed in each regional SDI category and were most marked in low SDI regions, with provincial 5-year survival ranging from 61·4% to 81·1% (hazard ratio [HR] 2·68 [95% CI 1·99–3·62] for mortality risk). Compared with intraprovincial patients (n=72 867; 5-year survival 76·4% [76·0–76·7]), interprovincial patients (n=22 322) had a significantly higher survival (79·9% [79·3–80·4]; HR 0·81 [0·78–0·84]). Higher socioeconomic areas had greater densities of health-care provision indicators for diagnosis and treatment. Based on scenario-based simulations, the key indicators associated with estimated reductions in mortality risk varied by region, but included the density of the pathology workforce and institutions providing surgery, radiotherapy, and post-treatment supportive care for paediatric cancer.
China has achieved major progress in childhood cancer survival, but inequalities remain across and within regions at different levels of socioeconomic development. The level of inequality appears greater among adolescents. While interprovincial health-care seeking was generally associated with higher survival, disparities in outcomes persisted, aligned with the socioeconomic development of patients' residence and treatment locations. Tiered resource allocation for paediatric cancer care at provincial and regional levels should be prioritised in China's health system to advance health equity.
作为可持续发展目标，为促进健康公平，及时评估癌症生存率的不平等至关重要。本研究旨在评估中国儿童及青少年癌症最新的全国范围5年生存率及生存差异，特别是与医疗可及性相关的差异。
基于国家儿童癌症监测中心（覆盖中国1388个监测点，占全国新发病例的82.3%）的数据，我们应用Kaplan-Meier法估算了2018年至2020年间诊断的95 189例0-19岁癌症患者的5年观察生存率。我们按年龄组、性别、癌症类型（基于第三版国际儿童癌症分类）、地区社会人口学指数（SDI）类别以及患者在居住省份内（省内）或省外（跨省）接受治疗的情况评估了生存率。我们根据其SDI分数（一个反映地区整体社会经济发展的综合指标）的分布，将31个省份划分为四个区域。我们考察了不同区域SDI类别之间以及各区域内部的生存差异。我们使用七项医疗资源供应指标（每1000名儿童及青少年）的密度作为医疗可及性的代理指标。我们应用随机生存森林模型，在模拟情景下（将省级指标密度设置为其实际值相对于全国或其所属区域SDI类别内观察到的最高水平），估算了省内患者死亡风险的潜在降低程度。
0-14岁儿童癌症患者的5年生存率为77.8%（95% CI 77.4–78.1），15-19岁青少年为75.3%（74.7–75.9），整个队列的总体5年生存率为77.2%（76.9–77.5）。女童生存率（79.0% [78.6–79.4]）高于男童（75.8% [75.4–76.2]）。在12个主要癌症组中，视网膜母细胞瘤生存率最高（91.2% [90.0–92.3]），而恶性骨肿瘤生存率最低（60.4% [59.0–61.9]）。就所有癌症合计而言，生存率从低SDI区域的72.6%（71.8–73.4）到高SDI区域的84.9%（83.8–86.1），表明社会经济地位较高区域的生存率显著更高（趋势p<0.0001）。高、低SDI区域间的绝对生存差异在青少年（13.4% [13.3–13.5]）中比在儿童（11.7% [11.7–11.8]）中更为显著。值得注意的是，各区域SDI类别内部均存在生存差异，且在低SDI区域最为明显，各省5年生存率范围为61.4%至81.1%（死亡风险的风险比[HR] 2.68 [95% CI 1.99–3.62]）。与省内患者（n=72 867；5年生存率76.4% [76.0–76.7]）相比，跨省患者（n=22 322）的生存率显著更高（79.9% [79.3–80.4]；HR 0.81 [0.78–0.84]）。社会经济水平较高地区在诊断和治疗相关的医疗资源供应指标密度上更高。基于情景模拟，与估计死亡风险降低相关的关键指标因区域而异，但包括病理专业人员和提供手术、放疗及治疗后支持性护理的儿科癌症相关机构的密度。
中国在儿童癌症生存率方面取得了重大进展，但在不同社会经济发展水平的区域之间及区域内部，不平等现象仍然存在。这种不平等程度在青少年中似乎更大。虽然跨省就医通常与较高的生存率相关，但结局差异仍然存在，且与患者居住地和治疗地点的社会经济发展水平相一致。为推进健康公平，在中国卫生系统中应优先考虑在省级和区域层面进行儿科癌症护理的分层资源配置。
肿瘤(癌症)患者之家