Interventions to reduce paediatric cancer treatment abandonment in low-income and middle-income countries: a systematic review and meta-analysis.
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BACKGROUND: Positive paediatric cancer treatment outcomes in low-income and middle-income countries (LMICs) significantly lag behind those in high-income countries. One reason for this disparity is high treatment abandonment rates in LMICs, defined as a failure to start or complete curative-intent therapy after a cancer diagnosis. We did a systematic review and meta-analysis to describe interventions aimed at reducing treatment abandonment in paediatric patients with cancer in LMICs. METHODS: In this systematic review and meta-analysis, we completed a comprehensive search of MEDLINE Ovid, Embase, Web of Science, CINAHL, and Cochrane on Oct 21, 2022, with an updated search on Oct 21, 2025. Studies were included if they met the following criteria: studied an intervention on treatment abandonment; included patients with cancer aged 18 years and younger; were conducted in LMICs as defined by the World Bank income classification; contained quantification of treatment abandonment by patients in a comparison and intervention group; and had a full-text article available. We restricted inclusion to English-language studies. We systematically assessed the quality of the studies and conducted a random-effects meta-analysis of risk ratios. FINDINGS: Among the 2263 articles identified across the two searches, 24 studies met the inclusion criteria. Among the studies, six (25%) were from the WHO African region, eight (33%) from the Americas, seven (29%) from the South-East Asia region, and three (13%) from the Western Pacific region. Most studies had notable methodological limitations, such as inconsistent definitions of abandonment, the absence of concurrent control groups, and reliance on simple abandonment proportions rather than time-to-event methods. The pooled risk ratio for treatment abandonment before and after intervention was 0·33 (95% CI 0·24-0·45; I2=88·0%). Ten (91%) of 11 studies that reported survival outcomes before and after intervention showed improvements in survival, although reporting was heterogeneous and often unadjusted. INTERPRETATION: Published evidence on interventions were associated with reduced paediatric cancer treatment abandonment in LMICs. These findings suggest that treatment abandonment is a targetable and potentially modifiable challenge in LMICs. Despite these encouraging findings, limitations of the evidence, including the absence of control groups, the absence of statistical rigour, and probable publication bias, restrict the generalisability of the results. Future studies should use standardised definitions of treatment abandonment, controlled designs, and time-to-event analysis methods. FUNDING: US National Institutes of Health, Alex's Lemonade Stand Foundation for Childhood Cancer, and The Rally Foundation for Childhood Cancer Care.