title: Determinants of Treatment Abandonment in Childhood Cancer: Results from a Global Survey.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, United States of America.
authors.forename: Paola
authors.identifier: http://orcid.org/0000-0002-5265-3113
authors.initials: P
authors.lastname: Friedrich
authors.affiliation: Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America.|Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America.
authors.forename: Catherine G
authors.initials: CG
authors.lastname: Lam
authors.affiliation: Institute of Child Health, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Geetinder
authors.initials: G
authors.lastname: Kaur
authors.affiliation: Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, United States of America.
authors.forename: Elena
authors.initials: E
authors.lastname: Itriago
authors.affiliation: Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America.
authors.forename: Raul C
authors.initials: RC
authors.lastname: Ribeiro
authors.affiliation: Department of Medical Oncology, Max Healthcare, New Delhi, India.
authors.forename: Ramandeep S
authors.initials: RS
authors.lastname: Arora
mesh_terms: D002648:Child; D003469:Culture; D006801:Humans; D009369:Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000453:epidemiology / Q000628:therapy*; D011379:Prognosis; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires