Shifting burden of childhood cancer mortality in the United States: progress and persistent inequities.

While 5-year survival following childhood cancer rose greatly from ~60% in the mid-1970s to 85% today, inequities persist and conventional survival metrics obscure the true burden and shifting distribution of deaths. To address this, we used Surveillance, Epidemiology, and End Results registries to evaluate excess mortality rates and counts (AER and AEC), new metrics quantifying mortality attributable to childhood cancer, among 47 545 US children diagnosed before age 20 during 1975-2014, with follow-up through 2018. We quantified trends across subgroups and assessed modification by county-level income and rurality. AER declined across groups but at different magnitudes. From 1975-1979 to 2010-2014, declines were 75% in non-Hispanic White (NHW), 62% in non-Hispanic Black, and ~63% in Hispanic and Asian/Pacific Islander children. Among non-Hispanic American Indian/Alaska Native children, AER fell briefly with no clear improvement subsequently. Absolute burden shifted: AEC fell among NHW (8874 in 1990-1994 to 5134 in 2010-2014) but rose among other subgroups (4826 to 5213). By 2010-2014, non-NHW children accounted for more deaths despite >15 000 fewer diagnoses than NHW children. These findings show a shifting national burden: Despite overall survival gains, persistent and sometimes worsening inequities mean deaths are increasingly concentrated among non-NHW subgroups.