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Socioeconomic inequalities in cancer incidence and access to health services among children and adolescents in China: a cross-sectional study


Background

Despite the substantial burden caused by childhood cancer globally, childhood cancer
incidence obtained in a nationwide childhood cancer registry and the accessibility
of relevant health services are still unknown in China. We comprehensively assessed
the most up-to-date cancer incidence in Chinese children and adolescents, nationally,
regionally, and in specific population subgroups, and also examined the association
between cancer incidence and socioeconomic inequality in access to health services.

Methods

In this national cross-sectional study, we used data from the National Center for
Pediatric Cancer Surveillance, the nationwide Hospital Quality Monitoring System,
and public databases to cover 31 provinces, autonomous regions, and municipalities
in mainland China. We estimated the incidence of cancer among children (aged 0–14
years) and adolescents (aged 15–19 years) in China through stratified proportional
estimation. We classified regions by socioeconomic status using the human development
index (HDI). Incidence rates of 12 main groups, 47 subgroups, and 81 subtypes of cancer
were reported and compared by sex, age, and socioeconomic status, according to the
third edition of the International Classification of Childhood Cancer. We also quantified
the geographical and population density of paediatric oncologists, pathology workforce,
diagnoses and treatment institutions of paediatric cancer, and paediatric beds. We
used the Gini coefficient to assess equality in access to these four health service
indicators. We also calculated the proportions of cross-regional patients among new
cases in our surveillance system.

Findings

We estimated the incidence of cancer among children (aged 0–14 years) and adolescents
(aged 15–19 years) in China from Jan 1, 2018, to Dec 31, 2020. An estimated 121 145
cancer cases were diagnosed among children and adolescents in China between 2018 and
2020, with world standard age-standardised incidence rates of 122·86 (95% CI 121·70–124·02)
per million for children and 137·64 (136·08–139·20) per million for adolescents. Boys
had a higher incidence rate of childhood cancer (133·18 for boys vs 111·21 for girls per million) but a lower incidence of adolescent cancer (133·92
for boys vs 141·79 for girls per million) than girls. Leukaemias (42·33 per million) were the
most common cancer group in children, whereas malignant epithelial tumours and melanomas
(30·39 per million) surpassed leukaemias (30·08 per million) in adolescents as the
cancer with the highest incidence. The overall incidence rates ranged from 101·60
(100·67–102·51) per million in very low HDI regions to 138·21 (137·14–139·29) per
million in high HDI regions, indicating a significant positive association between
the incidence of childhood and adolescent cancer and regional socioeconomic status
(p<0·0001). The incidence in girls showed larger variation (48·45% from the lowest
to the highest) than boys (36·71% from lowest to highest) in different socioeconomic
regions. The population and geographical densities of most health services also showed
a significant positive correlation with HDI levels. In particular, the geographical
density distribution (Gini coefficients of 0·32–0·47) had higher inequalities than
population density distribution (Gini coefficients of 0·05–0·19). The overall proportion
of cross-regional patients of childhood and adolescent cancer was 22·16%, and the
highest proportion occurred in retinoblastoma (56·54%) and in low HDI regions (35·14%).

Interpretation

Our study showed that the burden of cancer in children and adolescents in China is
much higher than previously nationally reported from 2000 to 2015. The distribution
of the accessibility of health services, as a social determinant of health, might
have a notable role in the socioeconomic inequalities in cancer incidence among Chinese
children and adolescents. With regards to achieving the Sustainable Development Goals,
policy approaches should prioritise increasing the accessibility of health services
for early diagnosis to improve outcomes and subsequently reduce disease burdens, as
well as narrowing the socioeconomic inequalities of childhood and adolescent cancer.

Funding

National Major Science and Technology Projects of China, National Natural Science
Foundation of China, Chinese Academy of Engineering Consulting Research Project, Wu
Jieping Medical Foundation, Beijing Municipal Administration of Hospitals Incubating
Program.



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