Neighborhood Poverty and End-of-Life Care Among Adolescents and Young Adults With Cancer

Among older adults with cancer, poverty is associated with end-of-life (EoL) care quality; however, its impact on care among adolescents and young adults (AYAs) is poorly understood. We examined the relationship between neighborhood poverty and EoL care among AYAs.

We identified AYAs with cancer who died between the ages of 12 and 39 years from 2003 to 2019 at Dana-Farber Cancer Institute, Kaiser Permanente Northern California, and Kaiser Permanente Southern California. Outcomes abstracted from medical records included care/treatment information, symptom evaluation, and psychosocial/spiritual care. Neighborhood poverty was derived by linking patient ZIP Code Tabulation Areas to the 2009 to 2013 American Community Survey. Multivariable logistic regression models assessed the relationship between neighborhood poverty and outcomes, adjusting for age at death, sex, race, ethnicity, cancer site, and care site.

Included AYAs (n=1,905) had median age of 30 years at diagnosis and 32 years at death; 55% were female, 61% were White, 27% were Hispanic/Latino, and 19% were from a high-poverty neighborhood. In bivariate analyses, compared with AYAs from low-poverty neighborhoods, AYAs from high-poverty neighborhoods were more likely to be hospitalized ≥2 times in their last 30 days (29% vs 22%; P=.004) and had lower hospice use (57% vs 64%; P=.008). Pain was assessed among 98% and was assessed less often among AYAs from high-poverty neighborhoods (96% vs 99%; P=.008). In multivariable analyses, AYAs from high-poverty neighborhoods had higher odds of >1 emergency department visit (odds ratio [OR], 1.33; 95% CI, 1.00-1.76) and >1 hospitalization in the last 30 days of life (OR, 1.33; 95% CI, 1.02-1.75), and lower odds of hospice use (OR, 0.76; 95% CI, 0.58-0.98).

Sustainable care delivery methods for patients who lack resources to address their EoL needs outside of the health care system are needed.