Delays in childhood cancer care at a tertiary care centre in Pakistan: a single-centre study.
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BACKGROUND: Timely diagnosis and initiation of therapy are critical determinants of survival in childhood cancer. In Pakistan, paediatric oncology services are highly centralised, and most children, particularly from rural and low-income households, experience prolonged delays with limited evidence on their cumulative magnitude and determinants. This study determined patient, diagnostic, treatment and health-system delays and identified predictors of prolonged total delay, defined as a cumulative interval exceeding 30 days from symptom onset to treatment initiation, among children with newly diagnosed malignancies. METHODS: Seventy-one children were analysed (median age 5 years; 67.6% male; 71.8% rural). Median total delay was 36 days interquartile range (IQR 49), with 57.7% experiencing prolonged delay. Survival and disease stage were significantly associated with delay duration; children with a total delay of 0-30 days achieved a 12-month event-free survival of 83.3%, which dropped to 60.0% for those with delays >90 days. Furthermore, 50.0% of children in the critical delay group presented with advanced Stages III or IV disease. Prolonged delay was independently associated with rural residence (adjusted OR 2.42), low household income (aOR 3.09), first healthcare contact outside a tertiary centre (aOR 3.96), lack of parental education, absence of caregiver awareness (aOR 2.85) and diagnosis of a solid tumour (aOR 2.67). RESULTS: Seventy-one children were analysed (median age 5 years; 67.6% male; 71.8% rural). Median total delay was 36 days (IQR 49), with 57.7% experiencing prolonged delay. Patient delay exceeded 14 days in 46.5%, while health-system delay affected 61.9%. Diagnostic delays beyond 21 days occurred in 25.4% and treatment delays were comparatively limited (18.3%). Prolonged delay was independently associated with rural residence (adjusted OR 2.42, 95% CI 1.16-5.03), low household income (< 50,000 PKR; aOR 3.09, 95% CI 1.42-6.72), first healthcare contact outside a tertiary centre (aOR 3.96, 95% CI 1.82-8.63), lack of parental education, absence of caregiver awareness of childhood cancer (aOR 2.85, 95% CI 1.29-6.31) and diagnosis of a solid tumour (aOR 2.67, 95% CI 1.29-5.53). CONCLUSION: Delays in childhood cancer care in Pakistan arise from socioeconomic vulnerability, geographic inequity and fragmented health-system pathways at this single-centre site. These delays directly correlate with advanced-stage presentation and reduced survival. Decentralised diagnostics, standardised referral systems, primary healthcare training, social support and community awareness are urgently needed to reduce delays and enhance survival in resource-constrained settings.