Early mortality in children with cancer in Denmark and Sweden: The role of social background in a setting with universal healthcare

Socioeconomic differences in overall survival from childhood cancer have been shown previously, but the underlying mechanisms remain unclear. We aimed to investigate if social inequalities were seen already for early mortality in settings with universal healthcare. From national registers, all children diagnosed with cancer at ages 0-19 years, during 1991-2014, in Sweden and Denmark, were identified, and information on parental social characteristics was collected. We estimated odds ratios (OR) and 95% confidence intervals (CI) of early mortality (death within 90 days after cancer diagnosis) by parental education, income, employment, cohabitation, and country of birth using logistic regression. For children with acute lymphoblastic leukaemia (ALL), clinical characteristics were obtained. Among 13,926 included children, 355 (2.5%) died within 90 days after diagnosis. Indications of higher early mortality were seen among the disadvantaged groups, with the most pronounced associations observed for maternal education (ORadj_Low_vs_High 1.65 [95% CI 1.22-2.23]) and income (ORadj_Q1(lowest)_vs_Q4(highest) 1.77 [1.25-2.49]). We found attenuated or null associations between social characteristics and later mortality (deaths occurring 1-5 years after cancer diagnosis). In children with ALL, the associations between social factors and early mortality remained unchanged when adjusting for potential mediation by clinical characteristics. In conclusion, this population-based cohort study indicated differences in early mortality after childhood cancer by social background, also in countries with universal healthcare. Social differences occurring this early in the disease course requires further investigation, also regarding the timing of diagnosis. In high-income countries in Europe, childhood cancer survival is suspected of being linked to socioeconomic status, despite mandates for equal access to healthcare. Little is known, however, about the impact of socioeconomic differences on early mortality in settings with universal healthcare. This study analyzed mortality following childhood cancer diagnosis in Sweden and Denmark. Early mortality was associated with socioeconomic status, wherein socially disadvantaged groups were at increased risk of death within three months of diagnosis. This was most clearly seen for maternal income and education. The relevance of socioeconomic differences on timing of childhood cancer diagnosis and survival warrants further investigation. image