Treatment abandonment in children with cancer: Does a sex difference exist? A systematic review and meta‐analysis of evidence from low‐ and middle‐income countries

Abstract

In this systematic review and meta-analyses, we sought to determine sex-disparities in treatment abandonment in children with cancer in low-and middle-income countries (LMICs) and identify the characteristics of children and their families most disadvantaged by such abandonment. Sex-disaggregated data on treatment abandonment were collated from the available literature and a random-effects meta-analysis was conducted to compare the rates in girls with those in boys. Subgroup analyses were conducted in which studies were stratified by design, cancer type and the Gender Inequality Index of the country of study. Eighteen studies were included in the systematic review and of these studies, 16 qualified for the meta-analysis, representing 10 754 children. The pooled rate of treatment abandonment overall was 30%. We observed no difference in the proportion of treatment abandonment in girls relative to estimates observed in boys (rate ratio [RR] 0.95, 95% CI: 0.79-1.15; P = .61). There was significant heterogeneity across the included studies and in the pooled estimate of RR for girls vs boys (both I 2 > 98%). Subgroup analyses did not reveal any effect on abandonment risk. Risk factors for abandonment observed fell into three main categories: socio-demographic; geographic; and travel-related. In conclusion, a high rate of treatment abandonment (30%) was observed overall for children with cancer in included studies in LMICs, although this was variable and context specific. No evidence of gender bias in childhood cancer treatment abandonment rates across LMICs was found. Given that the risk factors for abandonment are context specific, in-depth country-level analyses may provide further insights into the role of a child's gender in treatment abandonment decisions.

Impact of treatment refusal and abandonment on survival outcomes in pediatric osteosarcoma in Southeast Asia: A multicenter study

“…The prevalence of abandonment in South America was 18%, 12 which compares with 22% in the Asia‐Pacific region 24 . Abandonment among children with cancer is significantly high, up to 30%, in LMC 27,28 . Our study correspondingly found increased TxRA associated with the Philippines (LMIC) rather than Thailand (UMIC).…”

“…24 Abandonment among children with cancer is significantly high, up to 30%, in LMC. 27,28 Our study correspondingly found increased TxRA associated with the Philippines (LMIC) rather than Thailand (UMIC). On the contrary, Singapore (HIC) had significantly less TxRA compared with Thailand.…”

Risk factors associated with abandonment of care in retinoblastoma: analysis of 692 patients from 10 countries

“…Previous studies have come to various conclusions regarding sex and care abandonment. They range from finding child cancer care abandonment to be higher in LMICs, overall, with no sex bias 31 to finding female sex plays a minor role in childhood cancer treatment abandonment, but more so in LMIC than HIC 32 . Similarly, previous studies on RB have shown variable results in the significance of association between compliance and female sex.…”

Resource‐appropriate selection of osteosarcoma treatment protocols in low‐ and middle‐income countries

“…Available data from LMIC suggest that patients with bone sarcomas are more likely to abandon therapy, with maximum TA risk just before surgery (amputation) 81,93,95 . Risk factors for TA are geographic, travel‐related, and socio‐demographic or financial factors; a significant gender bias could not be identified from available heterogeneous data 25,93,101 . Experts suggest multiple interventions to reduce TA; like using locally adapted treatment protocols, emphasizing the need for such adaptations in LMIC 93,100–102 .…”

“…Risk factors for TA are geographic, travel‐related, and socio‐demographic or financial factors; a significant gender bias could not be identified from available heterogeneous data 25,93,101 . Experts suggest multiple interventions to reduce TA; like using locally adapted treatment protocols, emphasizing the need for such adaptations in LMIC 93,100–102 . Shorter, simpler, and outpatient‐based protocols may be more acceptable in the AYA population 46,63,78 .…”