Socio-economic Status Plays Important Roles in Childhood Cancer Treatment Outcome in Indonesia

  • Mostert, Saskia (Department of Pediatric Oncology-Hematology, VU University Medical Center) ;
  • Gunawan, Stefanus (Department of Pediatric Oncology-Hematology, Prof Dr. RD Kandou Hospital) ;
  • Wolters, Emma (Department of Pediatric Oncology-Hematology, VU University Medical Center) ;
  • van de Ven, Peter (Department of Epidemiology and Biostatistics, VU University Medical Center) ;
  • Sitaresmi, Mei (Department of Pediatrics, Dr. Sardjito Hospital, Gadjah Mada University) ;
  • van Dongen, Josephine (Department of Pediatric Oncology-Hematology, VU University Medical Center) ;
  • Veerman, Anjo (Department of Pediatric Oncology-Hematology, VU University Medical Center) ;
  • Mantik, Max (Department of Pediatric Oncology-Hematology, Prof Dr. RD Kandou Hospital) ;
  • Kaspers, Gertjan (Department of Pediatric Oncology-Hematology, VU University Medical Center)
  • Published : 2012.12.31


Background: The influence of parental socio-economic status on childhood cancer treatment outcome in low-income countries has not been sufficiently investigated. Our study examined this influence and explored parental experiences during cancer treatment of their children in an Indonesian academic hospital. Materials and Methods: Medical charts of 145 children diagnosed with cancer between 1999 and 2009 were reviewed retrospectively. From October 2011 until January 2012, 40 caretakers were interviewed using semi-structured questionnaires. Results: Of all patients, 48% abandoned treatment, 34% experienced death, 9% had progressive/relapsed disease, and 9% overall event-free survival. Prosperous patients had better treatment outcome than poor patients (P<0.0001). Odds-ratio for treatment abandonment was 3.3 (95%CI: 1.4-8.1, p=0.006) for poor versus prosperous patients. Parents often believed that their child's health was beyond doctor control and determined by luck, fate or God (55%). Causes of cancer were thought to be destiny (35%) or God's punishment (23%). Alternative treatment could (18%) or might (50%) cure cancer. Most parents (95%) would like more information about cancer and treatment. More contact with doctors was desired (98%). Income decreased during treatment (55%). Parents lost employment (48% fathers, 10% mothers), most of whom stated this loss was caused by their child's cancer (84% fathers, 100% mothers). Loss of income led to financial difficulties (63%) and debts (55%). Conclusions: Treatment abandonment was most important reason for treatment failure. Treatment outcome was determined by parental socio-economic status. Childhood cancer survival could improve if financial constraints and provision of information and guidance are better addressed.


Childhood cancer;socio-economic status;adherence;low-income country;Indonesia


  1. Al-Qudimat MR, Rozmus CL, Farhan N (2011). Family strategies for managing childhood cancer: using complementary and alternative medicine in Jordan. J Adv Nurs, 67, 591-7.
  2. AMPATH. Leading with care. Family Preservation Initiative (FPI). Available from:
  3. Arora RS, Eden T, Pizer B (2007). The problem of treatment abandonment in children from developing countries with cancer. Pediatr Blood Cancer, 49, 941-6.
  4. Arora RS, Pizer B, Eden T (2010). Understanding refusal and abandonment in the treatment of childhood cancer. Indian Ped, 475, 1005-10.
  5. Bonilla M, Rossell N, Salaverria C, et al (2009). Prevalence and predictors of abandonment of therapy among children with cancer in El Salvador. Int J Cancer, 125, 2144-6.
  6. Central Intelligence Agency. The World Factbook. Indonesia 2012. Available at:
  7. Hamidah A, Rustam ZA, Tamil AM, et al (2009). Prevalence and parental perceptions of complementary and alternative medicine use by children with cancer in a multi-ethnic Southeast Asian population. Pediatr Blood Cancer, 52, 70-4.
  8. Howard SC, Pedrosa M, Lins M, et al (2004). Establishment of a pediatric oncology program and outcomes of childhood acute lymphoblastic leukemia in a resource-poor area. JAMA, 291, 2471-5.
  9. Howard SC, Metzger ML, Wilimas JA, et al (2008). Childhood cancer epidemiology in low-income countries. Cancer, 112, 461-72.
  10. Lam C, Rossell N, Ribeiro RC (2012). Global snapshots of treatment abandonment in children and adolescents with cancer: social factors, implications and priorities. J Healthcare Science Human, 2, 81-110.
  11. McLean TW, Kemper KJ (2006). Complementary and alternative medicine therapies in pediatric oncology patients. J Soc Integr Oncol, 4, 40-5.
  12. Mostert S, Sitaresmi MN, Gundy CM, et al (2010). Comparing childhood leukaemia treatment before and after the introduction of a parental education programme in Indonesia. Arch Dis Child, 95, 20-5.
  13. Mostert S, Arora RS, Arreola M, et al (2011). Abandonment of treatment for childhood cancer: position statement of a SIOP PODC Working Group. Lancet Oncol, 12, 719-20.
  14. Mostert S, Njuguna F, L Kemps, et al (2012). Epidemiology of diagnosed childhood cancer in Western Kenya. Arch Dis Child, 97, 508-12.
  15. Mostert S, Gunawan S, van Dongen JAP, et al (Submitted). Health-care providers' perspectives on childhood cancer treatment in Manado, Indonesia
  16. Mostert S, Sitaresmi MN, Gundy CM, et al (2006). Influence of socioeconomic status on childhood acute lymphoblastic leukemia treatment in Indonesia. Pediatrics, 118, 1600-6.
  17. Mostert S, Sitaresmi MN, Gundy CM, et al (2008). Parental experiences of childhood leukemia treatment in Indonesia. J Pediatr Hematol Oncol, 30, 738-43.
  18. Naafs-Wilstra M, Barr R, Greenberg C, et al (2001). Pediatric oncology in developing countries: development of an alliance of stakeholders. Med Pediatr Oncol, 36, 305-9.<305::AID-MPO1069>3.0.CO;2-K
  19. Parkin DM, Stiller CA, Draper GJ, et al (1988). The international incidence of childhood cancer. Int J Cancer, 42, 511-20.
  20. Parkin DM, Kramarova E, Draper GJ, et al (1998). International Incidence of Childhood Cancer. Vol. II. Lyon, France: International Agency for Cancer Research pp. 1-391.
  21. Ricklefs MC (2001). Literary, religious and cultural legacies. the revolution, 1945-50. In: a history of modern Indonesia since c. 1200. Third edition. Great Britain: Palgrave 59-69, 261-86.
  22. Rokx C, Schieber G, Harimurti P, et al (2009). Health Financing in Indonesia: A Reform Road Map. Directions in Development: Human Development. World Bank. Available at:
  23. Sitaresmi MN, Mostert S, Schook RM, et al (2010). Treatment refusal and abandonment in childhood acute lymphoblastic leukemia in Indonesia: an analysis of causes and consequences. Psychooncology, 19, 361-7.
  24. Smith MA, Seibel NL, Altekruse SF, et al (2010) Outcomes for children and adolescents with cancer: challenges for the twenty-first century. J Clin Oncol, 28, 2625-34.
  25. Stam H, Grootenhuis MA, Brons PP, et al (2006). Health-related quality of life in children and emotional reactions of parents following completion of cancer treatment. Pediatr Blood Cancer, 47, 312-9.
  26. Yeh CH, Lin CF, Tsai JL, et al (1999). Determinants of parental decisions on drop-out from cancer treatment for childhood cancer patients. J Adv Nursing, 30, 193-9.

Cited by

  1. Health-care providers' perspectives on childhood cancer treatment in Manado, Indonesia vol.22, pp.11, 2013,
  2. Overview of Childhood Cancers at a Regional Cancer Centre in North-East India vol.15, pp.18, 2014,
  3. Parents' and Health-Care Providers' Perspectives on Side-Effects of Childhood Cancer Treatment in Indonesia vol.15, pp.8, 2014,
  4. Effect of a New Social Support Program by Voluntary Organization in Pediatric Oncology Department in a Developing Country vol.31, pp.3, 2014,
  5. Pediatric Malignancies, Treatment Outcomes and Abandonment of Pediatric Cancer Treatment in Zambia vol.9, pp.2, 2014,
  6. Financial Distress and its Predicting Factors among Iranian Cancer Patients vol.16, pp.4, 2015,
  7. Interventions targeting absences increase adherence and reduce abandonment of childhood cancer treatment in El Salvador vol.62, pp.9, 2015,
  8. Comparing Health-Care Providers' Perspectives on Complementary and Alternative Medicine in Childhood Cancer Between Netherlands and Indonesia vol.63, pp.1, 2015,
  9. Parental Experiences with Chemotherapy-Induced Alopecia among Childhood Cancer Patients in Indonesia vol.17, pp.4, 2016,
  10. Global Pediatric Oncology: Lessons From Partnerships Between High-Income Countries and Low- to Mid-Income Countries vol.34, pp.1, 2016,
  11. Caregivers' Self-Reported Absence of Social Support Networks is Related to Treatment Abandonment in Children With Cancer vol.63, pp.5, 2016,
  12. Enhancing the quality of life for palliative care cancer patients in Indonesia through family caregivers: a pilot study of basic skills training vol.16, pp.1, 2017,
  13. The role of Indonesian patients’ health behaviors in delaying the diagnosis of nasopharyngeal carcinoma vol.17, pp.1, 2017,
  14. Predictors of treatment abandonment for patients with pediatric cancer at Indus Children Cancer Hospital, Karachi, Pakistan pp.15455009, 2017,
  15. Unmet supportive care needs and psychological distress among parents of children with cancer in Indonesia pp.10579249, 2018,
  16. Baseline characteristics and outcomes of children with cancer in the English-speaking Caribbean: A multinational retrospective cohort vol.65, pp.12, 2018,
  17. A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries vol.8, pp.2, 2018,
  18. A framework to develop adapted treatment regimens to manage pediatric cancer in low- and middle-income countries: The Pediatric Oncology in Developing Countries (PODC) Committee of the International Pediatric Oncology Society (SIOP) vol.64, pp.15455009, 2018,
  19. Community resources support adherence to treatment for childhood cancer in El Salvador vol.36, pp.3, 2018,