State Mandatory Paid Family Leave and Survival among Children with Cancer

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Childhood cancer treatment is often costly and time intensive and may require parents/caregivers to stop working. Since 2012, several states have introduced mandatory paid family leave policies. We hypothesized that such policies, whether by reducing financial toxicity or by providing parents greater flexibility to care for their sick children, would improve outcomes among children with cancer. Children ages 0-18 years diagnosed with cancer between 2010 and 2019 were identified from the Surveillance, Epidemiology, and End Results program (SEER) database. The primary outcome was overall survival (OS). The exposure of interest was state mandatory paid family leave. Difference-in-differences (DID) analyses with additive hazards regression models were utilized to compare changes in OS from pre- to post- mandatory paid sick leave policy implementation in states with vs. without paid sick leave policies. The models were adjusted for year fixed effects, state fixed effects, state Medicaid expansion status, age, race, sex, metropolitan residence status, county-level income and education, cancer site, cancer stage, and insurance status. Clustered standard errors by state were achieved via the cluster bootstrap. The plausibility of the common trends assumption was tested using event study analyses and was satisfied for all analyses. A total of 38,053 children with cancer were identified. In adjusted difference-in-differences analyses, there was no significant change in OS in states with vs. without state mandatory paid family leave policies after policy enactment (hazard difference: 0.0001, 95% CI = -0.0002 to 0.0016, P = .47). However, among non-metropolitan residents, 1-year OS improved from 93.0% to 95.5% (2-year OS: 88.6% to 93.4%) in states with mandatory paid family leave policies compared to 92.7% to 92.5% (2-year OS: 88.0% to 87.7%) in states without such policies after policy enactment. This translates to a 2.7% improvement in 1-year OS (5.2%, 2-year OS) (hazard difference: -0.0021, 95% CI = -0.0034 to -0.0005, P = .037). There was no corresponding change for metropolitan residents (hazard DID = 0.0001, P = .47). By cancer site, the largest policy-associated improvements in survival were observed for rhabdomyosarcoma (hazard DID = -0.0037, P = .11), osteosarcoma (hazard DID = -0.0036, P<.001), and Intracranial and intraspinal embryonal tumors (hazard DID = -0.0026, P = .061). State mandatory paid family leave policies were associated with improved survival for some children with cancer, most notably for those residing in non-metropolitan areas. The improvements for non-metropolitan residents may be related to alleviating otherwise increased travel burdens for cancer treatment if treatment occurs out-of-town, where working while taking care of a child is less feasible. These data also suggest a slight narrowing in rural-urban-metropolitan childhood cancer disparities associated with paid family leave policies.