Rurality and pediatric cancer survival in the United States: An analysis of SEER data from 2000 to 2021

Background: Cancer is the leading cause of death by disease among children in the United States. Residing in rural areas may impact cancer outcomes as rural areas tend to have fewer available healthcare resources. Few population-based studies have investigated rural/urban disparities in pediatric cancer outcomes. The objective of this study was to examine rural/urban differences in (1) five-year relative survival and (2) cancer-specific survival among children in the United States. Methods: The study is a population-based longitudinal study using data from the Surveillance, Epidemiology, and End Results (SEER) 17 registries database (2000-2021). We included data for individuals aged 0-19 with a first primary malignant cancer diagnosed from 2000 to 2016. Rurality was measured by Rural-Urban Continuum Codes (RUCCs). Five-year relative survival rates, Kaplan-Meier curves, and Cox regression analysis were used to determine the differences in pediatric cancer survivorship between rural and urban areas. Results: Both five-year relative survival rates and log-rank tests of survival probabilities over time by rurality showed no statistically significant difference between individuals living in urban versus rural counties. However, after adjusting for age, sex, race/ethnicity, cancer type, median household income, and region, children diagnosed in rural counties had a 9 % higher risk of death compared to children diagnosed in urban counties (95 % CI 1.02-1.17), with the highest increased risk observed for children with retinoblastoma (aHR: 6.12, 95 % CI 2.01-18.59). A higher increased risk of death was observed for children living in the most rural counties (aHR: 1.18, 95 % CI 1.07-1.32). Conclusion: In this study, residing in rural areas was associated with an increased risk of death from pediatric cancer, especially for children residing in rural areas not adjacent to urban areas. Our findings warrant further investigation to determine the rural/urban disparities in pediatric cancer outcomes and to develop interventions to deliver high-quality cancer care to rural children.