Educational outcomes in childhood cancer survivors: A Scotland-wide record-linkage study of 766,217 schoolchildren

PLOS ONE RESEARCH ARTICLE Educational outcomes in childhood cancer survivors: A Scotland-wide record-linkage study of 766,217 schoolchildren Nicholas Baughan1, Jill P. Pell2, Daniel F. Mackay2, David Clark ID3, Albert King4, Michael Fleming ID2* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom, 2 School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom, 3 Public Health Scotland, Edinburgh, United Kingdom, 4 ScotXed, Scottish Government, Edinburgh, United Kingdom * Abstract OPEN ACCESS Citation: Baughan N, Pell JP, Mackay DF, Clark D, King A, Fleming M (2023) Educational outcomes in childhood cancer survivors: A Scotland-wide record-linkage study of 766,217 schoolchildren. PLoS ONE 18(7): e0286840. https://doi.org/ 10.1371/journal.pone.0286840 Editor: Sreeram V. Ramagopalan, University of Oxford, UNITED KINGDOM Received: February 9, 2023 Accepted: May 24, 2023 Published: July 26, 2023 Copyright: © 2023 Baughan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The datasets generated and analysed during the study are not publicly available. All health data are owned by Public Health Scotland (https://www. publichealthscotland.scot), and all education data are owned Scottish Government (www2.gov.scot/ Topics/Statistics/ScotXed). Under the terms of our data access agreements with them we are not permitted to pass the data onto third parties. Interested researchers may apply at these sites for data access to health and education data by emailing and Background A cancer diagnosis during childhood greatly disrupts the lives of those affected, causing physical and psychological challenges. We aim to investigate educational outcomes among schoolchildren with a previous cancer diagnosis compared to their peers. Methods Individual records from four national education databases and three national health databases were linked to construct a cohort of all singleton schoolchildren born in Scotland attending Scottish local-authority schools between 2009–2013. Pupils previously diagnosed with any cancer, haematological cancers, and central nervous system (CNS) cancers, were compared to their unaffected peers with respect to five educational outcomes: special educational need (SEN), absenteeism, school exclusion, academic attainment, and unemployment. Analyses were adjusted for sociodemographic and maternity factors and chronic conditions. Results Of 766,217 pupils, 1,313 (0.17%) had a previous cancer diagnosis. Children with any cancer had increased odds of SEN (OR 3.26, 95% CI 2.86–3.71), absenteeism (IRR 1.82, 95% CI 1.70–1.94), and low attainment (OR 2.15, 95% CI 1.52–3.03) compared to their peers. Similar findings were observed for haematological (SEN OR 2.62, 95% CI 2.12–3.24; absenteeism IRR 2.04, 95% CI 1.85–2.25; low attainment OR 2.17, 95% CI 1.31–3.61) and CNS (SEN OR 6.44, 95% CI 4.91–8.46; absenteeism IRR 1.75, 95% CI 1.51–2.04; low attainment OR 3.33, 95% CI 1.52–7.30) cancers. Lower exclusions were observed among children with any cancer (IRR 0.51, 95% CI 0.31–0.83) and CNS cancer (IRR 0.20, 95% CI 0.06–0.61). No associations were observed with unemployment. PLOS ONE | https://doi.org/10.1371/journal.pone.0286840 July 26, 2023 1 / 15 PLOS ONE respectively. The authors applied for permission to access, link, and analyse these data and undertook mandatory training in data protection, IT security and information governance. The study was approved by the National Health Service (NHS) Public Benefit and Privacy Panel and covered by a data processing agreement between Glasgow University and Public Health Scotland and a data sharing agreement between Glasgow University and ScotXed. The electronic Data Research and Innovation Service (eDRIS) within Public Health Scotland helped the authors obtain approvals, linked the data, and uploaded the final datasets into a secure analytical platform within the National Safe Haven for the researchers to analyse. The researchers did not receive any special privileges or access to the third-party data. Funding: The study was funded by Health Data Research UK (www.hdruk.ac.uk) (grant reference number MR/S003800/1). HDR UK is a joint investment led by the Medical Research Council, together with the National Institute for Health Research (England), the Chief Scientist Office (Scotland), Health and Care Research Wales, Health and Social Care Research and Development Division (Public Health Agency, Northern Ireland), the Engineering and Physical Sciences Research Council, the Economic and Social Research Council, the British Heart Foundation and Wellcome. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Educational outcomes in childhood cancer survivors Conclusions This study highlights the wider impacts of childhood cancer on educational outcomes. These children need to be supported, as poor educational outcomes can further impact later health. Background Around 130 children under the age of 15 years are diagnosed with cancer each year in Scotland, most of whom have haematological cancers (e.g., leukaemia, lymphoma) or cancers of the central nervous system (CNS) [1]. A cancer diagnosis during childhood greatly disrupts the lives of those affected, causing physical and psychological challenges not experienced by peers. Whilst formal cancer treatments can last several years [2], longer term adversities include the threat of cancer relapses, and the impact of the disease and treatment on malnutrition, growth, mental health, and even fertility [3–5]. In Scotland, overall five-year cancer survival among children diagnosed between 2009– 2013 was 83% (95% CI 80.4%–86.4%), therefore most will experience long-term consequences of cancer after leaving school [1]. Achieving a good education is a key wider determinant of health, influencing employment, wealth, standard of living, and overall wellbeing [6]. Therefore, identifying factors impacting educational outcomes is important to guide policy development, improve population health, and reduce health inequities. Whilst children with cancer face poorer health outcomes as a direct consequence of the condition, reduced educational performance may indirectly cause additional long-term adversity. Despite this, few population-wide studies have explored educational outcomes among schoolchildren with a previous cancer diagnosis and none have been conducted in the UK. Five educational outcomes were of interest for this study: special educational need (SEN), absenteeism, exclusion, academic attainment, (...truncated)