Document Type

Capstone Experience

Graduation Date


Degree Name

Master of Public Health



First Committee Member

Shinobu Watanabe-Galloway

Second Committee Member

Gary L. Cochran

Third Committee Member

Edward S. Peters

Fourth Committee Member

Kendra L. Ratnapradipa


Background: In the United States, five-year survival rates for pediatric (ages 0-19 years) cancer have improved since the mid-1970s due to treatment improvement. Research on adult cancer patients suggested rural patients have worse survival than urban patients. However, there is a dearth of research on survivorship among children and adolescents diagnosed with cancer.

Aims: The aims of the study were to: 1) examine differences in five-year relative survival rates of pediatric cancer in the United States between children living in urban and rural areas from 2000-2014 and 2) examine differences in a risk of dying from pediatric cancer between children living in urban and rural areas from 2000-2014 after adjusting for age, race/ethnicity, sex, cancer type, insurance status, and neighborhood socioeconomic status.

Methods: This was a retrospective, population-based cohort study using the Surveillance, Epidemiology, and End Results-17 registries data for individuals diagnosed with a first primary malignant cancer at ages 0-19 years from 2000 to 2014. Rurality was measured by Rural-Urban Continuum Codes (RUCCs). Adjusted hazard ratios (aHRs) and 95% confidence intervals (95% CIs) were calculated by Cox proportional hazards regression models. Effect modification by age group, sex, race/ethnicity, and cancer type was also assessed.

Results: Five-year relative survival rates were similar for individuals living in nonmetropolitan counties (95% CI 82.58%-83.23%) versus metropolitan counties (95% CI 81.29%-83.30%). Compared to individuals living in metropolitan counties, those living in nonmetropolitan counties had a significantly higher risk of cancer death (aHR 1.11; 95% CI 1.03-1.19) after adjusting for age, race/ethnicity, sex, cancer type and median household income. Race/ethnicity was a significant effect modifier (p

Conclusion: The results of the current study suggest that pediatric cancer survival in the United States varies by rural/urban residence as defined by RUCCs. Research studying the underlying causes of rural/urban disparities in cancer outcomes are needed to address barriers to high-quality care in rural areas.

Available for download on Wednesday, June 11, 2025