Causes for refusal or abandonment during treatment of pediatric acute promyelocytic leukemia

Financial hardship in families of children or adolescents with cancer: a systematic literature review

Financial hardship in childhood cancer contributes to poor health outcomes and global disparities in survival, but the extent of the financial burden on families is not yet fully understood. We systematically reviewed financial hardship prevalence and individual components characterising financial hardship across six domains (medical, non-medical, and indirect costs, financial strategies, psychosocial responses, and behavioural responses) and compared characteristics across country income levels using an established theory of human needs. We included 123 studies with data spanning 47 countries. Extensive heterogeneity in study methodologies and measures resulted in incomparable prevalence estimates and limited analysis. Components characterising financial hardship spanned the six domains and showed variation across country income contexts, yet a synthesis of existing literature cannot establish whether these are true differences in characterisation or burden. Our findings emphasise a crucial need to implement a data-driven methodological framework with validated measures to inform effective policies and interventions to address financial hardship in childhood cancer.

Early mortality continues to be a barrier to excellent survival in childhood acute promyelocytic leukemia: a retrospective study of 62 patients spanning 17 years

Data on childhood acute promyelocytic leukemia (APL) from low-and middle-income countries is limited. Early mortality is a concern and often not highlighted in clinical trials. The retrospective study was conducted on patients (≤12 years) with APL from 2003 to 2021 at a single center in India. Patients were treated with all-trans-retinoic acid (ATRA) and chemotherapy. Induction and three courses of consolidation were followed by maintenance for 2 years. In 2015, the protocol was updated with following modifications: (a) obtaining diagnostic cerebrospinal fluid at end-of-induction rather than at diagnosis, (b) administering intrathecal cytarabine regardless of risk-category, (c) risk-stratified administration of chemotherapy, and (d) inclusion of ATRA in all the cycles of consolidation. Sixty-two patients were diagnosed over the 17 years. The median age was 8 years (range: 0.9-12). Half had high-risk disease. Differentiation syndrome was observed in 32%, none being fatal. Eighteen (29%) patients died due to hemorrhage (83%) or septicemia (17%). Thirteen (21%) had early mortality (≤15 days), all due to hemorrhage. A platelet count <20 × 10⁹/L predicted early mortality (odds ratio: 4.5; 95% CI: 0.9-22, p = 0.06). Treatment abandonment reduced from 23.5% during 2003-2015 to nil during 2015-2021 (p = 0.006). Three (8%) patients relapsed. The 4-year OS of all patients and the patients who survived >15 days was 70.1% and 89.6%, respectively. The 4-year EFS, including abandonment and early mortality, before and following updated protocol, was 61.4% and 65.5%, respectively (p = 0.77). Early mortality continues to be a barrier to an otherwise excellent survival in childhood APL. A significant reduction in treatment abandonment in recent years is gratifying.

Treatment abandonment and refusal among children with central nervous system tumors in Jordan

BACKGROUND

Treatment abandonment and refusal are reported to contribute significantly to poor survival of children with cancer in low- and middle-income countries. We aimed to assess this phenomenon among children diagnosed with central nervous system (CNS) tumors in Jordan.

METHODS

We retrospectively reviewed the medical charts of children <18 years diagnosed with CNS tumors (2010-2020). Patients who abandoned or refused part of treatment were reviewed for their clinical characteristics, social circumstances, and possible reasons. We excluded patients referred for second opinion, radiotherapy only, or who traveled abroad for treatment.

RESULTS

Four hundred seventy-three Jordanian children were identified; 12 families (2.5%) abandoned treatment, and 15 refused part of therapy (3%). Most patients were females (67%) and most had good or moderate performance status (89%). Most families (93%) lived within 2 hours from King Hussein Cancer Center. Most parents were university graduates (71%) and all fathers were employed, while 71% of mothers were housewives. The most common reasons to abandon or refuse therapy were treatment intensity in view of poor tumor outcome or bad quality of life, conflicting recommendations from other health care providers, "personal beliefs" against chemotherapy, and preference to use alternative medicine.

CONCLUSIONS

Treatment abandonment and refusal in Jordanian children with CNS tumors is low. Universal cancer insurance, high level of education in the country, centralized cancer care in one institution, and the twinning program likely contributed to our low incidence. Improving knowledge on CNS tumors and better community rehabilitation and supportive services may help further decrease the abandonment and treatment refusal rate.

Adherence to childhood cancer treatment: a prospective cohort study from Northern Vietnam

OBJECTIVES

Global incidence and attention to childhood cancer is increasing and treatment abandonment is a major cause of treatment failure in low- and middle-income countries. The purpose of this study was to gain an understanding of factors contributing to non-adherence to treatment.

DESIGN

A prospective cohort study with 2 year follow-up of incidence, family-reported motives and risk factors.

SETTING

The largest tertiary paediatric oncology centre in Northern Vietnam.

PARTICIPANTS

All children offered curative cancer treatment, from January 2008 to December 2009.

PRIMARY AND SECONDARY OUTCOME MEASURES

Family decision to start treatment was analysed with multivariable logistic regression, and family decision to continue treatment was analysed with a multivariable Cox model. This assessment of non-adherence is thereby methodologically consistent with the accepted definitions and recommended practices for evaluation of treatment abandonment.

RESULTS

Among 731 consecutively admitted patients, 677 were eligible for treatment and were followed for a maximum 2 years. Almost half the parents chose to decline curative care (45.5%), either before (35.2%) or during (10.3%) the course of treatment. Most parents reported perceived poor prognosis as the main reason for non-adherence, followed by financial constraints and traditional medicine preference. The odds of starting treatment increased throughout the study-period (OR 1.04 per month (1.01 to 1.07), p=0.002), and were independently associated with prognosis (OR 0.51 (0.41 to 0.64), p=<0.0001) and travel distance to hospital (OR 0.998 per km (0.996 to 0.999), p=0.004). The results also suggest that adherence to initiated treatment was significantly higher among boys than girls (HR 1.69 (1.05 to 2.73), p=0.03).

CONCLUSIONS

Non-adherence influenced the prognosis of childhood cancer, and was associated with cultural and local perceptions of cancer and the economic power of the affected families. Prevention of abandonment is a prerequisite for successful cancer care, and a crucial early step in quality improvements to care for all children with cancer.

Preventing treatment abandonment for children with solid tumors: A single-center experience in Brazil

BACKGROUND

High rates of treatment abandonment have been considered one of the major limitations to achieving high cure rates of childhood cancer in developing countries. The aims of this study were to report the prevalence and factors associated with treatment abandonment for children diagnosed with solid tumors in one reference center in Brazil and to describe effective strategies to prevent it.

PROCEDURES

A retrospective review was conducted using data from 1139 children (0-18 years) treated for solid tumors at the Brazilian National Cancer Institute, during the period between January 2012 and December 2017. Treatment abandonment was defined as recommended by the International Society of Pediatric Oncology. The impact of implementing a patient-tracking system was evaluated. Descriptive statistics were used to analyze patient characteristics. Chi-square test was used for statistical analysis, with the significance level <0.05.

RESULTS

Of 1139 patients, 1.66% refused or abandoned treatment. Although from 2012 to 2013 there was an increase in the abandonment rate, it then decreased by 63.8% from 2013 to 2017 (2.5% to 0.9%). In the multivariate model, only retinoblastoma diagnosis was associated with abandonment (odds ratio = 5.0; 95% confidence interval, 1.2-20.4; P = 0.025). In our cohort, abandonment rates were not associated with increased death.

CONCLUSION

Monitoring missed appointments, and early interventions to address issues associated with providing resources to help families during treatment were effective in achieving very low abandonment rates.

Factors associated with abandonment of therapy by children diagnosed with solid tumors in Peru

BACKGROUND

Abandonment of treatment is a major cause of treatment failure and poor survival in children with cancer in low- and middle-income countries. The incidence of treatment abandonment in Peru has not been reported. The aim of this study was to examine the prevalence of and factors associated with treatment abandonment by pediatric patients with solid tumors in Peru.

METHODS

We retrospectively reviewed the sociodemographic and clinical data of children referred between January 2012 and December 2014 to the two main tertiary centers for childhood cancer in Peru. The definition of treatment abandonment followed the International Society of Paediatric Oncology, Paediatric Oncology in Developing Countries, Abandonment of Treatment recommendation.

RESULTS

Data from 1135 children diagnosed with malignant solid tumors were analyzed, of which 209 (18.4%) abandoned treatment. Bivariate logistic regression analysis showed significantly higher abandonment rates in children living outside the capital city, Lima (forest; odds ratio [OR] 3.25; P < 0.001), those living in a rural setting (OR 3.44; P < 0.001), and those whose parent(s) lacked formal employment (OR 4.39; P = 0.001). According to cancer diagnosis, children with retinoblastoma were more likely to abandon treatment compared to children with other solid tumors (OR 1.79; P = 0.02). In multivariate regression analyses, rural origin (OR 2.02; P = 0.001) and lack of formal parental employment (OR 2.88; P = 0.001) were independently predictive of abandonment.

CONCLUSION

Treatment abandonment prevalence of solid tumors in Peru is high and closely related to sociodemographical factors. Treatment outcomes could be substantially improved by strategies that help prevent abandonment of therapy based on these results.

Choosing a miracle: Impoverishment, mistrust, and discordant views in abandonment of treatment of children with cancer in El Salvador

OBJECTIVE

In El Salvador, at the only hospital offering pediatric oncology care, the number of children abandoning treatment for cancer has decreased in recent years (13%-3%). An investigation of caregivers' motives for abandonment was performed over 15 months from 2012 to 2014. Caregiver and health team perspectives on abandonment are reported using the explanatory model (EM) framework.

METHOD

Semistructured in-depth interviews and in hospital participant observations were conducted with caregivers of children diagnosed with cancer, who abandoned their child's treatment or were considering abandoning, and with members of the medical team.

RESULTS

Of the 41 caregivers interviewed, 26 caregivers (of 19 children) abandoned their child's treatment, returned from a series of missed appointments, or showed a risk of abandoning. Caregivers of 8 children stated that a miraculous cure was the main reason for abandoning; increasing impoverishment and misgivings toward treatment and outcomes were also mentioned. The responses of the medical team demonstrated a discordant EM for the child's cancer and treatment effects and that only biomedical treatment was effective for cure.

CONCLUSIONS

The caregivers' increasing impoverishment (not only financial) and misgivings about the child's treatment caused them to reconsider their therapeutic choices and rely on their belief in a miraculous cure, thus abandoning. The caregivers and medical team's discordant EM about the child's cancer and treatment must be acknowledged and shared decision making considered, together with consistency in the strategies that currently demonstrate to be effective decreasing abandonment.

Determinants of Treatment Abandonment in Childhood Cancer: Results from a Global Survey

BACKGROUND

Understanding and addressing treatment abandonment (TxA) is crucial for bridging the pediatric cancer survival gap between high-income (HIC) and low-and middle-income countries (LMC). In childhood cancer, TxA is defined as failure to start or complete curative cancer therapy and known to be a complex phenomenon. With rising interest on causes and consequences of TxA in LMC, this study aimed to establish the lay-of-the-land regarding determinants of TxA globally, perform and promote comparative research, and raise awareness on this subject.

METHODS

Physicians (medical oncologists, surgeons, and radiation therapists), nurses, social workers, and psychologists involved in care of children with cancer were approached through an online survey February-May 2012. Queries addressed social, economic, and treatment-related determinants of TxA. Free-text comments were collected. Descriptive and qualitative analyses were performed. Appraisal of overall frequency, burden, and predictors of TxA has been reported separately.

RESULTS

581 responses from 101 countries were obtained (contact rate = 26%, cooperation rate = 70%). Most respondents were physicians (86%), practicing pediatric hematology/oncology (86%) for >10 years (54%). Providers from LMC considered social/economic factors (families' low socioeconomic status, low education, and long travel time), as most influential in increasing risk of TxA. Treatment-related considerations such as preference for complementary and alternative medicine and concerns about treatment adverse effects and toxicity, were perceived to play an important role in both LMC and HIC. Perceived prognosis seemed to mediate the role of other determinants such as diagnosis and treatment phase on TxA risk. For example, high-risk of TxA was most frequently reported when prognosis clearly worsened (i.e. lack of response to therapy, relapse), or conversely when the patient appeared improved (i.e. induction completed, mass removed), as well as before aggressive/mutilating surgery. Provider responses allowed development of an expanded conceptual model of determinants of TxA; one which illustrates established and emerging individual, family, center, and context specific factors to be considered in order to tackle this problem. Emerging factors included vulnerability, family dynamics, perceptions, center capacity, public awareness, and governmental healthcare financing, among others.

CONCLUSION

TxA is a complex and multifactorial phenomenon. With increased recognition of the role of TxA on global pediatric cancer outcomes, factors beyond social/economic status and beliefs have emerged. Our results provide insights regarding the role of established determinants of TxA in different geographical and economic contexts, allow probing of key determinants by deliberating their mechanisms, and allow building an expanded conceptual model of established and emerging determinants TxA.

Contributing factors and outcomes of treatment refusal in pediatric oncology in Germany

BACKGROUND

In Germany, about 1,800 new cases of pediatric cancer under 15 years of age are diagnosed each year and survival rates approach 80%. Although treatment is covered by health insurance and is thus available for all patients at no cost, treatment refusal and treatment discontinuation have been observed. However, no data providing numbers and outcomes for developed countries have been published thus far.

PROCEDURE

A questionnaire-based survey was performed among German pediatric oncology centers to ascertain the number of treatment refusals among pediatric patients who were diagnosed between January 2008 and December 2009 in Germany.

RESULTS

Questionnaires from 70 of 73 centers were available, and of these 13 centers reported a total of 15 cases of treatment refusal or discontinuation within this 2-year period. Five of the 15 patients died, 7 of 15 were still alive, and the current status of 3 of 15 patients was unknown. Diseases were heterogeneous. Six of the 15 parents refused treatment for their children initially, 8 of 15 discontinued during the course of treatment. Five patients were treated after parental custody had been withdrawn due to the lack of compliance. All these five patients survived. Parents' reasons given for refusal or discontinuation of treatment were related to personal health beliefs and coping strategies.

CONCLUSIONS

Although treatment refusal or discontinuation is rare, it is accompanied by a high mortality rate. Parents' personal health beliefs play a primary role in treatment refusal or discontinuation in Germany. This emphasizes the importance of sustaining a functioning and mutually communicative physician-parent-patient relationship.

A 10-Year Follow-up Survey of Treatment Abandonment of Children With Acute Myeloid Leukemia in Suzhou, China

A survey of the clinical data on acute myeloid leukemia (AML) over the past 10 years in the treatment center of Children's Hospital was presented. The aim of the study was to identify the factors influencing the treatment abandonment rate (AR) of AML. Of the 474 AML cases examined, 264 were abandoned (55.7%). The most important factor affecting AR appeared to be the AML subtype-that is, the M3 versus non-M3 (42% vs. 60%). Patient age was observed to be closely related to AR-the older the patients, the lower the AR-and infants had the highest prevalence of abandonment (84.2%). The patient's residential location was markedly correlated to AR, which was almost inversely proportional to the size of the township where the patient came from. From large cities, intermediate and small towns to countryside villages, the AR increased linearly. So was the correlation with health insurance coverage, which decreased in the same way. Sex and karyotypes did not affect AR. In conclusion, the patients' financial burden and the perceived incurability of AML were the 2 leading factors dominating the decision for abandonment in parents and caregivers.

Caregivers' Self-Reported Absence of Social Support Networks is Related to Treatment Abandonment in Children With Cancer

BACKGROUND

Treatment abandonment (TxA) is a primary cause of therapy failure in children with cancer in low-/middle-income countries. We explored the absence of social support network (SSN), among other predictive factors, and TxA in children with cancer in Cali, Colombia.

PROCEDURE

In this prospective cohort study, we included children diagnosed with cancer at a public university hospital. A social worker and a psychologist administered semistructured questionnaires to patients' caregivers. We extracted information from the questionnaires about social, economic, and psychological conditions of the patients' families. Outcomes were death, relapse, and TxA. Failure either to start or to continue the planned course of curative treatment for 4 weeks or more was defined as TxA. We identified events with Cali's childhood cancer outcomes surveillance system (VIGICANCER). We adjusted the hazard ratios (HRs) for potential confounders using multivariate Cox regression analyses.

RESULTS

Among 188 patients diagnosed from January 2011 to June 2013, 99 interviews were conducted. Median age was 5 years old (range: 0.3, 14.9), 53% were male, 17% were of Colombian-Indian ethnicity, and 68% lived in rural areas. The 2-year cumulative incidence of TxA was 21% (95% confidence interval [CI]: 13, 35) and the annual proportion was 14%. The adjusted HR for the absence of SSN was 4.9 (95% CI: 1.6, 15.3).

CONCLUSIONS

We found a strong association between the absence of SSN and TxA that was independent of other covariates, including surrogate measures of wealth. Our findings highlight the imperative understanding of social ties and support surrounding children's families for planning strategies to prevent TxA.

Interventions targeting absences increase adherence and reduce abandonment of childhood cancer treatment in El Salvador

BACKGROUND

In El Salvador, about 200 new cases of pediatric cancer are diagnosed each year, and survival rates approach 70%. Although treatment is available at no cost, abandonment of therapy has remained at a steady yearly rate of 13% during the past decade. A time sensitive adherence tracking procedure (TS-ATP) was recently implemented to detect missed appointments, identify their causes, and intervene promptly. Procedure The study team was informed daily of patient/family failure to attend medical appointments in the pediatric oncology unit; the families were contacted and interviewed to ascertain and address the reasons. Patients who did not return after this initial contact were contacted again through local health clinics and municipalities. Law enforcement was a last resort for patients undergoing frontline treatment with a good prognosis., The system was adapted to clinical urgency: families of patients undergoing induction therapy were contacted within 24 hr, those in other therapy phases, within 48 hr, and those who had completed treatment, within one week. Reasons for absence were obtained by telephone or in person.

RESULTS

The annual rate of abandonment was reduced from 13-3% during the 2 years period. There were 1,111 absences reported and 1,472 contacts with caregivers and institutions. The three main reasons for absences were financial needs (165, 23%), unforeseen barriers (116, 16%), and domestic needs (86, 12%).

CONCLUSIONS

Use of the treatment adherence tracking system to locate and communicate with patients/families after missed appointments and the allocated aid stemming from these interviews substantially reduced abandonment and non-adherence.

Childhood cancer in El Salvador: A preliminary exploration of parental concerns in the abandonment of treatment

PURPOSE

In El Salvador, children under 12 diagnosed with cancer have access to free treatment at a specialized national facility. Until recently, 13 percent of patients annually abandoned therapy--a serious loss of lives and scarce resources. This qualitative study explores how some parents perceived their child's cancer and treatment, and what led them to stop bringing their child for chemotherapy.

METHOD

In in-depth interviews, parents of six children who abandoned their child's cancer treatment discussed sickness and life circumstances during the course of treatment.

RESULTS

Poverty, effects of treatment, mistrust, emotions and religious convictions all figured in the parents' explanation of their actions. However, each family weighed these concerns differently. It was the interaction of the concerns, and not the concern per se, that represented the explanatory frameworks the families used to explain stopping their child's treatment. This finding illustrates the parents' navigation among a collection of variable concerns, rather than exposing one fixed cause for their behavior. For example, poverty affects a parent's worldview as well as concrete living conditions, and therefore has a complex relationship with abandonment of treatment. Thus, it follows that strategies to reduce treatment abandonment (and increase a child's chance for survival) must be multidimensional.

CONCLUSIONS

Qualitative studies of how families perceive childhood cancer and treatment can illuminate the processes and relationships involved in abandonment of treatment. This approach can also show how families' living circumstances frame their perceptions and inform strategies to improve how medical services are provided, thus reducing abandonment of treatment.