Published online October 30, 2006
PEDIATRICS Vol. 118 No. 6 December 2006, pp. e1600-e1606 (doi:10.1542/peds.2005-3015)

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ARTICLE

Influence of Socioeconomic Status on Childhood Acute Lymphoblastic Leukemia Treatment in Indonesia

Saskia Mostert, MD^a, Mei N. Sitaresmi, MD^b, Chad M. Gundy, MS^c, Sutaryo, MD, PhD^b and Anjo J. P. Veerman, MD, PhD^a

^a Pediatric Hematology Oncology Division, Department of Pediatrics, Vrije University Medical Center, Vrije University, Amsterdam, the Netherlands
^b Pediatric Hematology Oncology Division, Department of Pediatrics, Dr Sardjito Hospital, Gadjah Mada University, Yogyakarta, Indonesia
^c Department of Psycho-Social Research and Epidemiology, Dutch Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands

OBJECTIVE. A major reason for poor survival of childhood acute lymphoblastic leukemia in developing countries is treatment refusal or abandonment. This can be associated with parental socioeconomic status and attitudes of health care providers. Our study examined the influence of 2 socioeconomic status determinants, parental income and education, on treatment in an Indonesian academic hospital.

METHODS. Medical charts of 164 patients who received a diagnosis of acute lymphoblastic leukemia between 1997 and 2002 were abstracted retrospectively. Data on treatment results and parental financial and educational background were collected. Open interviews were conducted with parents and health care providers.

RESULTS. Of all patients, 35% refused or abandoned treatment, 23% experienced treatment-related death, 22% had progressive or relapsed leukemia, and 20% had an overall event-free survival. Treatment results differed significantly between patients with different socioeconomic status; 47% of poor and 2% of prosperous patients refused or abandoned treatment. Although poor and prosperous patients used the same protocol, the provided treatment differed. Poor patients received less individualized attention from oncologists and less structured parental education. Strong social hierarchical structures hindered communication with doctors, resulting in a lack of parental understanding of the necessity to continue treatment. Most poor patients could not afford treatment. Access to donated chemotherapy also was inadequate. Treatment refusal or abandonment frequently resulted. There was no follow-up system to detect and contact dropouts. Health care providers were not fully aware that their own attitude and communication skills were important for ensuring compliance of patients and parents.

CONCLUSIONS. Children's survival of acute lymphoblastic leukemia in developing countries could improve if problems that are associated with parental financial and educational background and medical teams' attitudes to treatment and follow-up could be addressed better.

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Key Words: childhood acute lymphoblastic leukemia • compliance • socioeconomic status • developing country

Abbreviations: ALL—acute lymphoblastic leukemia • SES—socioeconomic status • COM-ALL-92—Comprehensive Protocol-Acute Lymphoblastic Leukemia-92 • WK-ALL-99—Wijaya Kusuma-Acute Lymphoblastic Leukemia-99

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Accepted Jun 28, 2006.

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