Place Matters: Predicting Positive and Negative Impacts of Cancer Among Childhood and Adolescent Cancer Survivors Residing in Rural Geographical Locations with Public Insurance

Background and Purpose: Childhood and adolescent cancer survivors (aged 0-19 years at diagnosis) face significant psychosocial stressors and life disruptions, yet little is known about how healthcare accessibility and insurance type impact their well-being. This study investigates these factors' effects in predicting both positive (e.g., health literacy, socializing) and negative impacts of cancer (e.g., life challenges, financial problems) on childhood and adolescent survivors compared to other survivor groups.

Methods: The study utilized secondary data collected from 2009 to 2019 from 470 participants at a childhood and adolescent survivorship clinic in the US Pacific Northwest who completed the Impact of Cancer-Childhood Survivors Scale (IOC-CS). The IOC-CS was developed to assess the comprehensive impact of cancer on survivors of childhood cancer. It incorporates the perspectives of survivors, healthcare professionals, and researchers to capture unique physical, emotional, social, and existential/spiritual cancer impacts. The IOC-CS consists of 45 items in which participants endorsed their experiences and perceptions of the impact of cancer on a 5-point Likert scale (1 = No impact to 5 = Great impact). The negative impact of cancer (NIOC) includes 20 items organized by three subscales: life challenges, thinking and memory problems, and financial problems; the positive impact of cancer (PIOC) consists of 25 items grouped with five subscales: health literacy, socializing, body and health, talking with parents, and personal growth. Participants' geographical designation as rural or not was determined using zip code by U.S. Census Bureau guidelines. Insurance information was collected through patient records and matched with the date/year participants completed the first IOC-CS questionnaire. Hierarchical regression analysis explored the influence of demographic factors, environmental factors, and interaction effects. A sequential blockwise entry method was employed, incorporating demographic factors (e.g., age at diagnosis, biological sex, race/ethnicity, cancer type), followed by environmental factors (e.g., geographical location, insurance type), and interaction effects (e.g., age at diagnosis × biological sex, geographical location × insurance type).

Results: Of the 470 participants, ages ranged from 14 to 55 (mean = 26.7, SD = 7.3); 79% were childhood and 21% were adolescent cancer survivors. Just under half of participants were identified as female (49%, n = 230). There were 344 (73%) non-Hispanic White/Caucasian cancer survivors (vs. n = 100, 21% non-white). Hematological cancers accounted for 60% (n=283), CNS/brain tumors accounted for 11% (n=52), while solid and soft tissue tumors and other cancers accounted for 29% (n=135). Results reveal that the interaction effect of living in a rural geographical location with public insurance was a risk factor for increasing NIOC indicated by increased life challenges, thinking/memory problems, and financial problems (β = 0.13, p = 0.05) after controlling for years since diagnosis and other demographic and environmental factors.

Conclusions: The findings highlight critical implications for social work practice and policy in oncology settings. Social workers must prioritize understanding the unique needs of survivors in rural areas with public insurance. Strategies like telehealth and peer support services can enhance healthcare accessibility, and partnerships with rural agencies can improve support services for these survivors.