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


Despite the significant burden of childhood cancer worldwide, the incidence of childhood cancer in a nationwide childhood cancer registry and the accessibility of relevant health services in China are still unknown. We comprehensively assessed the most recent cancer incidence in Chinese children and adolescents at national, regional and specific population subgroups, and also examined the association between cancer incidence and socioeconomic inequality in access to health services.


In this national cross-sectional study, we used data from the National Center for Pediatric Cancer Surveillance, the nationwide hospital quality surveillance system, and public databases to cover 31 provinces, autonomous regions, and municipalities in mainland China. We estimated cancer incidence in children (aged 0–14 years) and adolescents (aged 15–19 years) in China by stratified proportional estimation. We classified regions by socioeconomic status using the Human Development Index (HDI). The incidence rates of 12 major 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 geographic and population densities of pediatric oncologists, pathologists, childhood cancer diagnostic and treatment facilities, and pediatric beds. We used the Gini coefficient to assess equity in access to these four health service indicators. In addition, we calculated the proportion of national patients in the new cases in our surveillance system.

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We estimated the incidence of cancer in children (aged 0-14 years) and adolescents (aged 15-19 years) in China from January 1, 2018 to December 31, 2020. In children and adolescents, an estimated 121,145 cases of cancer were diagnosed in China between 2018 and 2020, with age-standardized world standard 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 youth. 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 cancer in adolescents (133.92 for boys vs 141.79 for girls per million) than girls. Leukemia (42.33 per million) was the most common cancer group in children, while malignant epithelial tumors and melanoma (30.39 per million) surpassed leukemia (30.08 per million) as the highest incidence cancer in adolescents. 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 childhood and adolescent cancer incidence and regional socioeconomic status (p<0·0001). The incidence in girls showed larger differences (48.45% from lowest to highest) than in boys (36.71% from lowest to highest) in different socioeconomic regions. The population and geographic density of most health services also showed a significant positive correlation with HDI scores. In particular, the geographic density distribution (Gini coefficients of 0.32–0.47) showed greater inequalities than the population density distribution (Gini coefficients of 0.05–0.19). The overall proportion of supraregional patients with pediatric cancer was 22.16%, and the highest proportion occurred in retinoblastoma (56.54%) and in low HDI regions (35.14%).

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Our study showed that the cancer burden among children and adolescents in China is much higher than previously reported nationally from 2000 to 2015. The distribution of health service accessibility as a social determinant of health could play a notable role in socioeconomic inequalities in cancer incidence among Chinese children and adolescents. With a view to achieving the Sustainable Development Goals, policy approaches should prioritize improving the accessibility of health services for screening to improve outcomes and subsequently reduce the burden of disease, and reduce the socioeconomic inequalities of childhood and adolescent cancer.

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China National Major Science and Technology Projects, National Natural Science Foundation of China, Chinese Academy of Engineering Consultancy Research Project, Wu Jieping Medical Foundation, Beijing Municipal Hospital Hospital Incubation Program.

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