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

Xin Ni; Zhe Li; Xinping Li; Xiao Zhang; Guoliang Bai; Yingying Liu; Rongshou Zheng; Yawei Zhang; Xin Xu; Yuanhu Liu; Chenguang Jia; Huanmin Wang; Xiaoli Ma; Huyong Zheng; Yan Su; Ming Ge; Qi Zeng; Shengcai Wang; Junyang Zhao; Yueping Zeng; Guoshuang Feng; Yue Xi; Zhuo Deng; Yongli Guo; Zhuoyu Yang; Jinzhe Zhang

doi:10.1016/S0140-6736(22)01541-0

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

Lancet. 2022 Sep 24;400(10357):1020-1032. doi: 10.1016/S0140-6736(22)01541-0.

Authors

Xin Ni¹, Zhe Li², Xinping Li³, Xiao Zhang³, Guoliang Bai³, Yingying Liu³, Rongshou Zheng⁴, Yawei Zhang⁵, Xin Xu⁶, Yuanhu Liu⁷, Chenguang Jia⁸, Huanmin Wang⁹, Xiaoli Ma¹⁰, Huyong Zheng¹¹, Yan Su¹⁰, Ming Ge¹², Qi Zeng¹³, Shengcai Wang⁷, Junyang Zhao¹⁴, Yueping Zeng¹⁵, Guoshuang Feng¹⁶, Yue Xi⁶, Zhuo Deng⁶, Yongli Guo¹⁷, Zhuoyu Yang¹⁸, Jinzhe Zhang³

Affiliations

¹ National Center for Pediatric Cancer Surveillance, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China. Electronic address: ncpcs@bch.com.cn.
² National Center for Pediatric Cancer Surveillance, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; School of Biological Science and Medical Engineering, Beihang University, Beijing, China.
³ National Center for Pediatric Cancer Surveillance, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
⁴ Office for Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
⁵ Department of Cancer Prevention and Control, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
⁶ Information Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
⁷ Department of Otolaryngology Head and Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
⁸ Stem Cell Transplantation Department, Medical Administration Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
⁹ Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹⁰ Medical Oncology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹¹ Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹² Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹³ Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹⁴ Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹⁵ Department of Medical Record Management, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹⁶ Big Data Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹⁷ Beijing Key Laboratory for Pediatric Diseases of Otolaryngology, Head and Neck Surgery, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
¹⁸ Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

PMID: 36154677
DOI: 10.1016/S0140-6736(22)01541-0

Abstract

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.

MeSH terms

Adolescent
Child
China / epidemiology
Cross-Sectional Studies
Female
Health Services
Health Services Accessibility
Humans
Incidence
Leukemia*
Male
Neoplasms* / diagnosis
Neoplasms* / epidemiology
Socioeconomic Factors