Disparities in Area Socioeconomic Development and Pediatric Cancer Survival in Romania—A National Pediatric Registry Study on Multiple Geographic Levels

Background/Objectives: Socioeconomic indicators and geographic factors influence pediatric cancer outcomes, but evidence in Romania is limited. Methods: This retrospective cohort study included 6247 patients aged 0–19 years diagnosed with cancer and recorded in the Romanian National Pediatric Oncology and Hematology Registry between 1 January 2010, and 31 December 2024. Kaplan–Meier analysis was used to estimate the survival probabilities across four strata of regional and county socioeconomic categorization and two strata of community marginalization status. Unadjusted and multivariable Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for sex, age group, primary cancer type (ICCC-3), tumor behavior, and geographical residence. Subgroup analyses assessed the association between rurality and pediatric cancer survival, irrespective of community marginalization status. Results: Survival probabilities were consistently lower among patients residing in more socioeconomically disadvantaged regions, counties, and marginalized communities (log-rank p ≤ 0.0001). In the most deprived strata, 5-year survival for regions, counties, and communities was 69.86% (95% CI: 67.49–72.10), 67.47% (95% CI: 63.32–71.26), and 65.51% (95% CI: 61.33–69.35), respectively. In adjusted models, residence in the least deprived regions (HR = 0.783, 95% CI = 0.744–0.952) and counties (HR = 0.749, 95% CI = 0.620–0.905) was associated with improved survival, a 22% and 25% lower risk of death, respectively, compared with residence in the most deprived categories. Community marginalization was associated with lower survival outcomes in unadjusted analyses, but was not significant after adjustment. Rural residence was associated with a 44% higher risk of death (HR = 1.436, 95% CI = 1.304–1.582), with a 5-year survival of 66.76% (95% CI: 64.91–68.53) among rural patients, compared with 75.93% (95% CI: 74.28–77.48) in urban patients. Conclusions: This is Romania’s first pediatric cancer survival study to evaluate persistent social and geographical disparities. Survival outcomes were consistently lower in more socioeconomically disadvantaged regions and counties, while the findings suggest that rural residence may explain the observed differences in survival at the community level. Policymakers and health systems in Romania should focus on covering pediatric cancer patients with appropriate proximity services across the entire national territory, thus enabling all patients to get timely access to quality care.