title: Low socioeconomic status is associated with worse survival in children with cancer: a systematic review.
abstract: BACKGROUND
  While low socioeconomic status (SES) has been associated with inferior cancer outcome among adults, its impact in pediatric oncology is unclear. Our objective was therefore to conduct a systematic review to determine the impact of SES upon outcome in children with cancer.
  
  
  METHODS
  We searched Ovid Medline, EMBASE and CINAHL from inception to December 2012. Studies for which survival-related outcomes were reported by socioeconomic subgroups were eligible for inclusion. Two reviewers independently assessed articles and extracted data. Given anticipated heterogeneity, no quantitative meta-analyses were planned a priori.
  
  
  RESULTS
  Of 7,737 publications, 527 in ten languages met criteria for full review; 36 studies met final inclusion criteria. In low- and middle-income countries (LMIC), lower SES was uniformly associated with inferior survival, regardless of the measure chosen. The majority of associations were statistically significant. Of 52 associations between socioeconomic variables and outcome among high-income country (HIC) children, 38 (73.1%) found low SES to be associated with worse survival, 15 of which were statistically significant. Of the remaining 14 (no association or high SES associated with worse survival), only one was statistically significant. Both HIC studies examining the effect of insurance found uninsured status to be statistically associated with inferior survival.
  
  
  CONCLUSIONS
  Socioeconomic gradients in which low SES is associated with inferior childhood cancer survival are ubiquitous in LMIC and common in HIC. Future studies should elucidate mechanisms underlying these gradients, allowing the design of interventions mediating socioeconomic effects. Targeting the effect of low SES will allow for further improvements in childhood cancer survival.
authors.affiliation: Division of Haematology/Oncology, the Hospital for Sick Children, Toronto, Ontario, Canada ; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada ; Program in Child Health Evaluative Sciences, the Hospital for Sick Children, Toronto, Ontario, Canada ; Institute for Health, Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Sumit
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Division of Haematology/Oncology, the Hospital for Sick Children, Toronto, Ontario, Canada ; Program in Child Health Evaluative Sciences, the Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Marta
authors.initials: M
authors.lastname: Wilejto
authors.affiliation: Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada ; Institute for Clinical and Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Pole
authors.affiliation: Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada ; Institute for Clinical and Evaluative Sciences, Toronto, Ontario, Canada ; Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada ; Institute for Health, Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Astrid
authors.initials: A
authors.lastname: Guttmann
authors.affiliation: Division of Haematology/Oncology, the Hospital for Sick Children, Toronto, Ontario, Canada ; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada ; Program in Child Health Evaluative Sciences, the Hospital for Sick Children, Toronto, Ontario, Canada ; Institute for Health, Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Lillian
authors.initials: L
authors.lastname: Sung
mesh_terms: D002648:Child; D006801:Humans; D012923:Social Class; D017741:Survivors