Ac-DEVD-CHO The principal causes of refusal in the present
The principal causes of refusal in the present study were financial constraints and belief in the incurability of cancer. Our center caters mainly to poor patients, as 70% of our children (392/572) were of lower socioeconomic status (Table 2); this may be a plausible explanation for financial constraints being the most important cause of refusal, further evidenced by the fact that refusal decreased with improving socioeconomic status. Other studies have also found lower socioeconomic status to be an important predictor for refusal [15,19,20], emphasizing the necessity for financial support (either through government or non-government organizations) and availability of subsidized chemotherapeutic drugs to prevent parents from refusing to treat their children with cancer. The belief that cancer is incurable was responsible for 22% of treatment refusals at our center. This misbelief has been documented as an important cause in other studies as well [4,21,22]. Lower educational status of the father was a major predictor for refusal in the present study. Intensive counselling at the time of diagnosis by trained counsellors about the curability of cancer, particularly focusing on parents with lower educational status, would possibly prevent refusal, more so in centers with a paucity of trained oncologists. The higher refusal rate in girls as compared to boys (23.4% versus 15.2%) reflects the gender bias in Indian society, with preferential treatment being given to males. Abandonment of treatment in the present study, seen in 29.2% of the patients (139/476), was similar to that in reports from other tertiary-care hospitals in India (Chandigarh and West Bengal) [11,12]. Studies from China, Indonesia and Iran have also documented comparable abandonment rates, whereas higher abandonment was found in Kenya (54%), probably because the majority of the Ac-DEVD-CHO (>50%) live below the poverty line and have very poor medical insurance coverage [13,15,25,26]. Specialized cancer centers in our country, however, reported much lower abandonment rates (<10%) [23,24]; these being referral centers, the majority of parents are sincerely committed to treatment, which could account for the lower abandonment rates. Studies from Brazil, Mexico, Turkey, Guatemala, El Salvador, and Central America found lower abandonment rates than those in the present study, varying from 0.5% to 12% [16,17,18,27,28,29]. This study found that the majority of children abandoned treatment during induction, and the main reasons cited by them were financial difficulties. The cost of treatment was fully covered by parents in the initial part of the study period. Later, despite the treatment being highly subsidized, a few chemotherapeutic drugs and antibiotics had to be purchased by care-givers because these drugs were not available in the hospital pharmacy. Major cost issues in the induction phase included use of expensive chemotherapeutic drugs such as L-asparaginase, along with increased incidence of infections often requiring expensive antibiotics, as well as a greater need for blood products, and these may explain abandonment in this phase. Other studies too found the majority of abandonments during induction [15,28,8]. Abandonment was significantly higher in children with lower hemoglobin values, possibly because of pressure on the family to arrange for donors as a large proportion of blood donations in our blood bank are family donations. This is probably due to increased demand for blood products at our blood bank, making it difficult to accomplish by voluntary donation. Poor general condition of the child was another major reason for abandonment in our study, especially during induction and consolidation, probably due to more aggressive therapy during these phases leading to non-resolving infections or treatment-related complications. This highlights the need for appropriate counselling of parents during these phases, communicating that the poor clinical condition of their child is not due to cancer per se but to infection, which can be well controlled by antibiotics. Treatment-related toxicity and painful procedures have been documented as reasons for abandonment in other studies as well [4,15,18]. Providing adequate sedation for painful procedures such as lumbar puncture and bone-marrow biopsy would be highly beneficial in preventing abandonment.