Learn why disadvantaged kids often face decreased cognition post-brain cancer treatment.

A recent study conducted by scientists at St. Jude Children’s Research Hospital has shed light on the significant role of socioeconomic environment in the cognitive outcomes of pediatric brain tumor patients undergoing radiation therapy. 

press release announced the study, published in Neuro-Oncology. It suggests that neighborhood-level economic hardship can predict both these patients’ baseline and long-term cognitive outcomes.

The Role of Environment in Cognitive Outcomes for St. Jude Patients With Brain Tumors

The research team, led by Heather Conklin, Ph.D., from the St. Jude Department of Psychology and Biobehavioral Sciences, found that children living in supportive environments demonstrated better cognitive outcomes than those residing in economically challenged neighborhoods. After undergoing radiation therapy, the latter group exhibited worse baseline and long-term cognitive outcomes, particularly in math skills.

Conklin emphasized that the patient’s environment significantly influences cognitive outcomes beyond the diagnosis or treatment received. The family, neighborhood, and available support systems also play a crucial role.

Dr. Conlin said this about the study:

“At the simplest level, we found that a patient’s environment matters. It’s not just the diagnosis or treatment the patient receives. It’s also the family, neighborhood, and support they can access that predicts cognitive outcomes.”

St. Jude

The Economic Hardship Index and Recovery From Brain Tumors

The St. Jude study used an innovative tool known as the Economic Hardship Index (EHI) to delve deeper into the relationship between neighborhood-level economic hardship and cognitive outcomes in pediatric brain tumor patients. The EHI is a comprehensive framework that quantifies the level of economic hardship in a given neighborhood, providing a more nuanced understanding of the socioeconomic conditions that patients come from.

Dr. Conklin explained why that matters. “Economic hardship at the neighborhood level predicted how these patients performed cognitively at baseline, before radiation therapy, and then also based on what EHI quartile they were, how much they declined or stayed stable over time.”

What Are the Factors That Predict This?

The EHI comprises six key factors that collectively paint a picture of the economic conditions in a neighborhood. These factors are the following:

1. Unemployment: 

This data measures the proportion of the workforce without employment and actively seeking work. High unemployment rates can indicate economic instability and hardship.

2. Dependency: 

This factor refers to the proportion of the population dependent on welfare or other forms of government assistance. A high dependency rate can suggest a lack of sufficient income and resources within the community.

3. Education: 

This factor assesses the educational attainment levels within the neighborhood. Lower levels of education can limit job opportunities and contribute to economic hardship.

4. Income: 

This data measures the average income of households within the neighborhood. Lower average incomes can indicate a higher level of economic hardship.

5. Crowded Housing: 

This factor looks at the number of occupants per dwelling in a neighborhood. Overcrowded housing can indicate insufficient income to afford larger or additional housing.

6. Poverty: 

This measure looks at the proportion of the population below the poverty line. High poverty rates are a direct indicator of economic hardship.

brain tumors

Why Is This Information Necessary for Retaining Cognition in Children with Brain Tumors?

The data for these factors is collected at the census block level, a geographical unit used by the United States Census Bureau. But what is a census block? It is the smallest geographic measurement utilized by the U.S. Census Bureau and typically includes between 250 and 550 housing units. This granular level of data collection allows the EHI to capture the economic conditions of virtually every neighborhood in the United States, providing a comprehensive view of the economic landscape across the country.


By using the EHI, the researchers were able to correlate neighborhood-level economic conditions with cognitive outcomes in patients, providing valuable insights into the role of socioeconomic factors in health outcomes. This approach underscores the importance of considering the broader social and economic context in which patients live when assessing their health and designing interventions.

The researchers discovered a higher EHI score correlated with patients who began treatment with lower cognitive abilities and those who experienced a more significant cognitive decline post-treatment. The predictive power of the EHI rivaled known risk factors for cognitive decline in these patients, such as age at radiation therapy.

“Even though St. Jude is at the forefront of pediatric brain tumor care, there are still challenges for our patients,” Conklin explained. “St. Jude patients receive physical, occupational and speech therapy while they’re here, but they still go back home to their neighborhoods that maybe are higher in crime or have poorer schools or are overcrowded. They may not have access to the same resources once their treatment concludes and they return to their community.”

The Importance of Neighborhood-Level Assessment

This study is the first in the oncology field to use a neighborhood-level variable, rather than a family-specific measure, to predict cognitive outcomes in children treated for brain tumors. This approach provides a more nuanced understanding of the child’s living context and opens new avenues for developing interventions to improve cognitive outcomes.

Despite receiving state-of-the-art care at no cost at St. Jude, patients still face challenges when returning to their neighborhoods. For instance, they may face high crime rates, poor schools, or overcrowding. These environmental conditions, rather than individual choices, significantly affect long-term outcomes. Therefore, solutions addressing these factors could benefit current and future pediatric patients with brain tumors.

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Final Thoughts on Changing Practice to Protect Cognition in Children With Brain Tumors 

While the EHI can predict poor cognitive outcomes beyond traditional treatment and clinical risk factors, it is not yet ready for widespread clinical adoption. Clinicians need to be sensitive and resourceful when helping patient families from high EHI areas to protect their child’s cognitive health proactively.

Conklin suggests that clinicians could recommend enriching activities that fit with the caregiver’s schedule and resources to help prevent cognitive decline. These activities should be accessible, free, and feasible for families with single parents or multiple children.

The study found that social or policy interventions might help. Patients from higher socioeconomic status neighborhoods had better baseline and long-term cognitive outcomes. By increasing access to resources for families from lower socioeconomic status, clinicians and policymakers can better protect against cognitive decline in pediatric patients treated with radiation for brain tumors.

Grants from the National Cancer Institute and ALSAC, the fundraising and awareness organization of St. Jude, supported the study.