br Authorship contributions br Ethics br Conflicts of intere
Conflicts of interest
Introduction Acute lymphoblastic leukemia (ALL) is the most common malignancy in children, comprising a quarter of all childhood cancers. In India the age-adjusted incidence rates of pediatric leukemia range from 35.7 to 61.3 per million for boys and 22.3 to 40.2 per million for girls . With the advent of combination chemotherapy and risk-stratified protocols, the current cure rate for childhood ALL in high-income countries (HICs) has improved from about 10% in the 1960s to 85–90% or more . In India, a low- to middle-income country (LMIC), cure rates are still low except in a few centers of excellence, despite the use of treatment protocols similar to those in the West [3,4]. This survival gap between HICs and LMICs is multifactorial and includes different biological profiles, advanced stage of disease at diagnosis, high rates of malnutrition, illiteracy, poor average per-capita income, low government health expenditure, associated co-morbidities, lack of supportive care, severity of toxicities, and inadequate hygiene along with a high incidence of infection-related mortality [4,5]. Another important yet often overlooked cause is the disparities that exist between healthcare infrastructures of these two categories of countries regarding effective pediatric cancer care . Refusal (non-initiation) and abandonment (non-completion) of treatment are among leading causes of treatment failure, and studies focusing on the causes of refusal or abandonment of treatment in children with ALL from India are scanty . Thus the current study primarily aims to identify the prevalence and reasons behind treatment refusal/abandonment in childhood ALL in a tertiary-care public-sector teaching hospital situated in North India over a Phosphatase Inhibitor Cocktail II of 18 years, and to understand the predictors for refusal and abandonment.
Methods King George’s Medical University, Lucknow, is a large, public-sector, multispecialty, 3000-bed tertiary-care teaching hospital in North India. This retrospective, observational study was conducted at the Pediatric Hematology–Oncology division, which is one of the major centers dedicated to pediatric oncology in a state with a population of 204 million residing in area of 243,286 km2 (rural 77.7%, urban 22.3%) . The majority of our patients come from rural areas (villages); they are not well connected with the city, and they use multiple modes of public transport which are available at government-subsidized rates. The hospital is public sector and overcrowded, and most of our population is of lower socioeconomic status. The hospital is a busy center which registers approximately 300–400 new pediatric cancer cases annually. Patients admitted include those who approach the hospital emergency/outpatient department (OPD) directly (the majority) as well as those who are referred from other centers for specialized care. No charges for physician, nursing, bed or diet are exacted in the hospital, but patients have to pay for a few drugs, laboratory services, radiology, admission, and OPD visits, all of which are highly subsidized. Each child is allowed to be accompanied by two attendants at a time in the hospital wards. Ethical approval was obtained from the Ethics Committee of the King George’s Medical University before the start of the study, with reference to code 66th ECM II-B/P17th (# 1257/Rcell 14).
Discussion In the present study, the refusal rate was 16.8% (96/572) in children admitted with ALL. Studies from Chandigarh and West Bengal documented even higher rates of refusal (24–30%) [11,12]. Among developing countries, similar rates were found in China , although one study from China quoted a much higher rate (53%) ; lower rates (12%) were documented in a study from Indonesia . Remarkably, refusal was reported absent in studies from Brazil, Mexico and Turkey [16,16,17].