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. 2026 Jan-Dec:33:10732748251414200.
doi: 10.1177/10732748251414200. Epub 2026 Jan 16.

Geographic and Socioeconomic Determinants of Treatment Abandonment in Pediatric Acute Leukemia: A Cohort Study in South-Central Mexico

Juan Carlos Núñez-Enriquez  1 , Nuria Citlali Luna-Silva  2 , Karen Jacuinde-Trejo  3 , Janet Flores-Lujano  4 , Daniela Medina-León  5 , Erika Alarcón-Ruiz  6 , Miguel Ángel Garrido-Hernández  7 , Cynthia Shanat Cruz-Medina  7 , Diana Tinoco-Montejano  8 , Ma Del Rocío Baños-Lara  9   10 , María de Los Ángeles Del Campo-Martínez  11 , David Aldebarán Duarte-Rodríguez  12 , Aldo Allende-López  4 , Diana Casique-Aguirre  13   14 , Jesús Elizarrarás-Rivas  15 , Daniela Olvera-Caraza  7 , Juan Carlos Solís-Poblano  16 , Vanesa Terán-Cerqueda  16 , Dalia Ramírez-Ramírez  13 , Andrea Huerta-Moreno  16 , Pierre Mitchel Aristil-Chery  17 , Rubí Romo-Rodríguez  13 , Enoch Alvarez-Rodríguez  18   19 , Lourdes Esthela Juan Lien-Chang  20 , Gabriela Zamora-Herrera  13 , Brianda García Hidalgo  20 , Wilfrido Herrera-Olivares  20 , Guillermo José Ruíz-Arguelles  21 , Moisés Manuel Gallardo-Pérez  21 , Lénica Anahí Chávez-Aguilar  19 , Aquilino Márquez-Toledo  22 , Lena Sarahí Cano-Cuapio  23 , Raquel Hernández Ramos  23 , María Angélica Martínez-Martell  2 , Anabel Beatriz Ramirez-Ramirez  24 , Nalyn Rodriguez Brindis  24 , Alvaro José Montiel-Jarquín  25 , César Alejandro Galván-Díaz  26 , Liliana Velasco-Hidalgo  26 , Aurora Medina-Sanson  27 , María de Lourdes Gutiérrez-Rivera  28 , Alan Cárdenas-Conejo  29 , Adrián Morales-Maravilla  30 , Nora Patricia Victorio-García  28 , Vilma Carolina Bekker-Méndez  31 , María de Los Ángeles Romero-Tlalolini  32 , Juan Carlos Rodríguez-Espinosa  9   10 , Minerva Mata-Rocha  14   33 , Amanda Idaric Olivares-Sosa  34 , Haydeé Rosas-Vargas  33 , Silvia Jiménez-Morales  35 , Martha Eugenia Juárez Martínez  9 , Mariana Cárdenas-González  36 , Juan Manuel Mejía-Aranguré  37   38 , Enrique López-Aguilar  11 , Marta Zapata-Tarrés  39 , Rosana Pelayo  13   40
Affiliations

Geographic and Socioeconomic Determinants of Treatment Abandonment in Pediatric Acute Leukemia: A Cohort Study in South-Central Mexico

Juan Carlos Núñez-Enriquez et al. Cancer Control. 2026 Jan-Dec.

Abstract

IntroductionPediatric acute leukemia is the most common childhood malignancy and one of the leading causes of cancer-related mortality worldwide, particularly, in low- and middle-income countries (LMICs), where treatment abandonment remains a major barrier to survival. Geographic accessibility and socioeconomic conditions are recognized determinants, but their combined influence in Mexico remains understudied. This study evaluated the association between geographic accessibility, socioeconomic factors, and treatment abandonment among children with acute leukemia in south-central Mexico.MethodsA prospective cohort study was conducted in Oaxaca, Puebla, and Tlaxcala from 2021 to 2023, including 574 children under 18 years diagnosed with acute lymphoblastic or myeloid leukemia. Geographic accessibility was estimated using travel distance and time from patients' residences to referral hospitals, calculated with ORS Tools in QGIS. Socioeconomic variables included public health insurance affiliation, parental education and occupation, and number of siblings. Treatment abandonment was defined per SIOP criteria as failure to initiate or discontinuation of treatment for ≥4 consecutive weeks. Multivariable logistic regression, adjusted for child's sex, age, year of diagnosis, and leukemia subtype, was used to assess associations.ResultsTreatment abandonment occurred in 16.6% of patients. In multivariable analysis, lack of public health insurance (aOR = 2.83; 95% CI: 1.39-5.76; P < 0.01) and living ≥141 km from the hospital (aOR = 1.68; 95% CI: 1.02-2.74; P = 0.03) were significantly associated with abandonment. Other factors, including number of siblings, maternal education, and fathers' occupation, were not statistically significant.ConclusionLack of public health insurance and greater distance to the hospital are key determinants of treatment abandonment in children with acute leukemia in south-central Mexico. Expanding insurance coverage, reducing indirect costs, and addressing geographic barriers are critical to improve treatment adherence and survival outcomes in this population.

Keywords: geographic accessibility; pediatric leukemia; public health insurance; socioeconomic factors; treatment abandonment.

Plain language summary

Leukemia is the most common type of cancer in children. Today, many children can be cured if they receive full treatment on time. However, in some places, children do not finish their treatment. This is called “treatment abandonment,” and it is one of the main reasons why children die of leukemia in low- and middle-income countries. In this study, we followed 574 children under 18 years old with leukemia in Oaxaca, Puebla, and Tlaxcala between 2021 and 2023. We looked at two main factors: how far families live from the hospital and their socioeconomic situation, including whether they had public health insurance. We measured the distance from the children’s homes to the hospitals and collected information about parents’ education, work, and family size. We found that about 17 out of every 100 children (16.6%) abandoned their treatment. Two main reasons explained this: not having public health insurance and living far away from the hospital. Children without health insurance were almost three times more likely to stop treatment, and those living more than 141 kilometers away were about 1.7 times more likely to abandon it. Other family factors, such as the number of siblings or parents’ education level, did not have a strong impact. These results show that distance and lack of insurance are the biggest barriers to completing leukemia treatment in this region of Mexico. To save more lives, it is important to expand access to health insurance, reduce the hidden costs of care, and find ways to support families who live far from hospitals.

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Conflict of interest statement

Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Geographic distribution of childhood leukemia cases by distance to treatment centers and area of residence in Puebla, Oaxaca, and Tlaxcala (2021-2023). The map illustrates the spatial distribution of childhood leukemia cases according to residential distance to the corresponding tertiary care hospital. Green diamonds represent patients living <141 km from the hospital, and orange circles indicate those residing ≥141 km. Treatment centers are marked with red crosses. Urban areas are shaded brown and rural areas beige. Panels (a, b) provide focused views of contrasting regions: (a) an urban cluster with a high concentration of cases within 141 km, and (b) a rural zone with dispersed cases located ≥141 km from the hospital. This figure highlights the spatial component of geographic accessibility, one of the key variables examined in relation to treatment abandonment
See this image and copyright information in PMC

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