Spatial Epidemiology of Pediatric Cancer in Romania: A Decade of Persistence, Continuity, and Localized Hotspots (Temporal Trend 2008-2017).

Objective: Pediatric cancer, though less prevalent than adult malignancies, constitutes a significant public health concern due to its long-term effects on survival, development, and quality of life. This study aimed to investigate spatial patterns and temporal trends of pediatric cancer in Romania over a ten-year period (2008-2017), identifying persistent and emerging geographic hotspots using Geographic Information Systems (GIS)-based modelling and spatial statistics. Methods: A national pediatric cancer registry provided by the Ministry of Health was analyzed for cases among individuals aged 0-18 years, categorized by administrative-territorial units (ATUs), ICD-10 codes, sex, and year. Spatial indicators of persistence (recurrent prevalence across multiple years) and continuity (uninterrupted recurrence) were computed. Hotspot analysis was conducted using Local Moran's I, and trend patterns were assessed through temporal modeling. Additionally, fractal and complexity metrics were applied to characterize the spatial structure and heterogeneity of cancer persistence and continuity across regions. Results: Although national pediatric cancer prevalence exhibited a modest decline from 3.57‱ in 2008 to 3.44‱ in 2017, GIS-based spatial modeling revealed stable high-risk clusters in Central and South-Eastern Romania, particularly in historically industrialized counties such as Hunedoara, Prahova, and Galați. These correspond to regions with past heavy industry and chemical pollution. Male children presented a higher frequency of malignant tumors (48,502 cases in males vs. 36,034 in females), while benign and uncertain-behavior neoplasms increased more prominently among females (from 3847 to 4116 cases, compared with 3141 to 3199 in males). Several rural localities showed unexpected prevalence spikes, potentially associated with socioeconomic deprivation, limited health literacy, and reduced access to pediatric oncology services. Regional disparities in diagnostic and reporting capacities were also evident. Conclusion: GIS-based spatial epidemiology proved effective in revealing localized, sex-specific, and persistent disparities in pediatric cancer across Romania. The integration of spatial indicators and complexity metrics into national cancer control programs could strengthen early detection, optimize resource allocation, and reduce health inequities. These findings highlight the value of combining geospatial analysis and fractal modeling to guide evidence-based public health strategies for pediatric oncology.