Kira Bona, MD
Material Hardship in Families of Children with Cancer
While we've made huge strides in childhood cancer treatment, nearly 20% of children still die of their disease, and all children endure side effects during therapy. My research aims to understand the contribution of poverty to outcomes for children with cancer and their families. The goal of my research is to identify social factors that contribute to childhood cancer mortality, and symptoms and suffering during treatment. While we know that poverty is associated with poor health in pediatric primary care and children with chronic illness, we don't know how poverty impacts the health of children with cancer. It is not hard to imagine that families who struggle to put food on the table may have less time to focus on the appropriate dose of pain medication for disease-related pain, or timing of home oral chemotherapy administration. Nor is it difficult to imagine that families with fewer resources may rely more heavily on the Emergency Department for symptom management. Efforts to improve care and outcomes for children with cancer require consideration of such social determinants of health.
My research aims to begin clarifying this relationship by understanding how common poverty is in the childhood cancer population, and how it changes over time during therapy. I am completing a 2-year survey study of families of children newly diagnosed with cancer at Dana‐Farber/Children's Hospital Cancer Center examining material hardship—a concrete indicator of poverty that considers access to basic living needs, such as food, shelter, and heat. My ASCO funded research aims to use information from this study to first identify how common material hardship is both at the beginning of cancer therapy and after six months of chemotherapy. Next, I will use this information to develop a screening tool which can be used in future research to identify childhood cancer families at-risk for material hardship, and to study the relationship between poverty and childhood cancer outcomes. My research project will lay the groundwork for future larger studies to further examine this relationship, and will importantly help us design ways to improve pediatric cancer outcomes related to poverty.
Grant Term: July 1, 2013 - December 30, 2014
While we've made huge strides in childhood cancer treatment, nearly 20% of children still die of their disease, and all children endure side effects during therapy. I am interested in understanding the contribution of poverty to these pediatric cancer outcomes. The goal of my research is to identify targetable social factors involved in residual childhood cancer morbidity and mortality.
We know that poverty is associated with negative health outcomes in pediatric primary care and chronic illnesses, we don't know how poverty impacts pediatric cancer outcomes. My research funded by ASCO aimed to begin clarifying this relationship by defining the prevalence of material hardship—-a concrete measure of poverty assessing basic living needs, such as food, shelter, and heat—-in the pediatric cancer population. Material hardship is an easily measured type of poverty which we know can be improved with feasible interventions in the medical setting. Consequently, if pediatric cancer families are experiencing material hardship then it can serve as a target for future research on outcomes as well as a target for interventions.
My ASCO-funded study showed high rates of material hardship—-including food, housing or energy insecurity—-during chemotherapy treatment despite the fact that families were cared for by a team which included both doctors and social workers. Twenty percent of families reported at least one material hardship including food, housing or energy insecurity prior to their child's cancer diagnosis. Despite good social work supports, following six-months of chemotherapy this number had increased to 29% of families reporting food, housing or energy insecurity. Additionally, 25% of families had lost 40% annual household income due to cancer-related work disruptions.
We conclude that material hardship is present in a significant proportion of newly diagnosed pediatric oncology families at a large referral center, and that despite social work supports, the proportion of families experiencing such basic needs as food, housing or energy insecurity increases during chemotherapy to nearly one in three families. Material hardship provides a quantifiable and targetable measure of poverty in pediatric oncology. Interventions to reduce these concretely targetable measures of poverty could benefit a significant proportion of pediatric oncology families.
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My research aims to elucidate the role of poverty in mediating pediatric oncology outcomes, with the eventual goal of developing interventions to improve quality of life and child outcomes. First steps in clarifying this relationship include describing the prevalence of targetable measures of poverty in the pediatric cancer population, and developing screening instruments for use in the clinical setting.
My research funded by the Conquer Cancer Foundation of ASCO has focused on two distinct projects: 1) Completion of data analysis of the 2-year longitudinal cohort study "Economic Resource Needs in Families of Children Newly Diagnosed with Cancer" (EIS); and 2) Completion of a PHIS database analysis exploring the relationship between family income and patterns of care for children with cancer. Since initiation of my Conquer Cancer funding in July 2014, I have successfully completed the bulk of my proposed research and have made significant strides toward next steps in my career with regard to grant submission and project development.
A1. Specific Aim 1: To conduct an analysis of data collected in the 2-year longitudinal cohort study "Economic Resource Needs in Families of Children Newly Diagnosed with Cancer" (EIS) to identify the proportion of pediatric oncology families experiencing material hardship 1) at the time of diagnosis and 2) following 6 months of cancer-directed therapy. Hypothesis 1: Ten percent of families will develop material hardship by 6 months into treatment.
Progress: Manuscript to be submitted this week to JCO for consideration for publication. Briefly, we performed a prospective cohort study including 99 English-speaking families of children receiving chemotherapy for primary cancer (response rate 88%). Families completed face-toface surveys 1) Within 30 days of child's diagnosis; 2) 6-months following diagnosis. Material hardship was assessed in three domains: food, energy and housing insecurity. Results of this study demonstrated strikingly high rates of concrete resource needs—including food, housing or energy insecurity during chemotherapy treatment despite robust psychosocial supports. Twenty percent of families reported low-income and at least one material hardship including food, housing or energy insecurity prior to their child's cancer diagnosis. Following six-months of chemotherapy, 25% of families lost >40% annual household income secondary to treatmentrelated work disruptions and 29% of families report food, housing or energy insecurity. We conclude that low-income and material hardship are prevalent in a significant proportion of newly diagnosed pediatric oncology families at a large referral center. Despite psychosocial supports, the proportion of families experiencing such basic needs as food, housing or energy insecurity increases during chemotherapy to nearly one in three families. Material hardship provides a quantifiable and remediable measure of poverty in pediatric oncology. Interventions to ameliorate these concretely targetable measures of poverty could benefit a significant proportion of pediatric oncology families.
A2. Specific aim 2: To determine factors associated with material hardship at 6 months into cancer therapy and with these design a brief clinical screening tool able to predict 90% of families who will develop material hardship at 6-months into cancer therapy. Hypothesis 2: The following variables will be associated with the development of material hardship: baseline family federal poverty level, baseline material hardship, single parent status, and cancer diagnosis. Progress: Univariate analyses revealed a statistically significant relationship between the presence of material hardship at 6-months and baseline family federal poverty level, baseline material hardship, lower parental education, and single parent status. In multivariate analysis, baseline material hardship alone is significantly related with the presence of material hardship at 6 months. We have identified a short and feasible survey tool to be utilized in subsequent pediatric oncology clinical trials to identify and track material hardship.
A3. Specific aim 3: To conduct a pilot study assessing the feasibility of validating the clinical screening tool against the gold standard comprehensive EIS instrument. Hypothesis 3: Validation of the clinical screening tool will be highly feasible in terms of willingness to participate and participant burden. Progress: We have decided not to pursue this aim with our current data given limitations of sample size to generate meaningful validation results. We anticipate formal validation of our material hardship screening survey in an upcoming multi-center clinical trial of children with pediatric ALL.
A4. Specific aim 4: To test the relationship between family income and rates of emergency room visits/unplanned admissions among children with cancer. We hypothesize that lower family income is correlated with higher rates of unplanned hospital admissions and ED visits and longer lengths-of-stay for pediatric oncology patients.
Progress: Data analysis has been completed and manuscript submission is in preparation.
January 23, 2017 Update
Dr. Kira Bona is an Instructor in Pediatric Hematology/Oncology at Dana-Farber/Boston Children's Cancer and Blood Disorders Center in Boston, MA. She is a pediatric oncologist with a clinical focus on leukemia, and a clinical researcher focused on improving disease outcomes in pediatric cancer by systematically intervening on social determinants of health, such as poverty. As an early career investigator under the mentorship of Dr. Joanne Wolfe she has developed content expertise in the areas of financial hardship and measures of poverty in pediatrics. Her work to date has demonstrated an association between community-level poverty and higher risk of early relapse in children with acute lymphoblastic leukemia (ALL) in the clinical trial setting. She has additionally identified a high rate of a targetable measure of poverty (household material hardship (HMH)—defined as food, housing or energy insecurity) in the pediatric oncology setting. Her current project, funded by a K07 from NIH/NCI, leverages the uniform care delivery setting of a clinical trial to investigate the impact of HMH on relapse, overall survival and chemotherapy adherence in the context of a multicenter clinical trial for pediatric ALL (DFCI 16-001). These data will lay the groundwork for future research testing a poverty-targeted intervention in the clinical trial setting.
While we've made huge strides in childhood cancer treatment, nearly 20% of children still die of their disease, and all children endure side effects during therapy. My research aims to improve our cancer survival rates by understanding the impact of poverty on childhood cancer outcomes, and designing and testing poverty-targeted interventions where needed.
We know that poverty is associated with negative health outcomes in pediatric primary care and chronic illnesses, how poverty impacts pediatric cancer outcomes is less well understood. Additionally, figuring out the best way to measure poverty to allow for future interventions is an outstanding question. Dr. Bona's CCF/Strike 3 Foundation YIA research project determined that a targetable measure of poverty (household material hardship—a concrete measure of poverty assessing basic living needs, such as food, shelter, and heat) is common in pediatric cancer families. Nearly 1 in 3 families at a major academic medical center reported food, housing or heat insecurity after 6 months of chemotherapy (Bona K et al. Pediatric Blood and Cancer 2015). In subsequent work, Dr. Bona's research group found that children with acute lymphoblastic leukemia (ALL) who come from high-poverty communities are more likely to experience a hard-to-treat type of relapse called Early Relapse than children who come from low-poverty communities (Bona K et al. Pediatric Blood Cancer 2016). Dr. Bona's current project builds on these results. With funding from the National Cancer Institute, she is studying whether household material hardship is related to disease outcomes (risk of early relapse and survival), adherence to oral chemotherapy, and need for Emergency Department visits or ICU stays in the context of a multi-center clinical trial for children with ALL. The long-term goal of this work is to design poverty-targeted interventions to improve childhood cancer outcomes.
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