Survey of pediatric solid tumor care in economically underdeveloped regions of China

Abstract

Background

Despite advancements in pediatric oncology in China, disparities in the diagnosis and treatment of pediatric solid tumors persist, especially in economically underdeveloped regions. This study evaluates the landscape of pediatric solid tumor care in these areas, focusing on clinicians’ knowledge, diagnostic and treatment capabilities, training needs, and perceived barriers to improving care quality.

Methods

A cross-sectional survey was conducted among clinicians specializing in pediatric solid tumors in 14 economically underdeveloped provinces of China. The survey assessed clinicians’ self-reported knowledge, diagnostic and treatment practices, training participation, and perceived barriers. Data were collected online and analyzed using descriptive statistics.

Results

A total of 259 responses were included. The majority of respondents were male (58.30%), with a median age of 39 and 11 years of pediatric experience. While most clinicians reported high theoretical knowledge (69.5%), 59.07% attended to fewer than 10 cases annually. Treatment capacities varied, with chemotherapy (94.56%) and surgery (92.05%) widely available, but limited access to radiotherapy (43.93%), targeted therapy (46.86%), immunotherapy (43.93%), and bone marrow transplantation (37.66%). Multidisciplinary team (MDT) implementation was insufficient, with 45.95% lacking MDTs. Most clinicians (96.13%) expressed a high need for further training, especially in clinical guidelines, disease recognition, and early screening. Key barriers included insufficient policy support (67.57%) and lack of standardized protocols (44.79%).

Conclusion

Clinicians from underdeveloped regions face challenges like low case volumes, limited training, and resource constraints. Targeted interventions, including enhanced training, resource allocation, and policy support, are essential to improving care and outcomes for children with solid tumors in these regions.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-15087-9.

Introduction

With the continuous advancement of medical technology and improvements in healthcare infrastructure, the overall level of pediatric oncology care in China has significantly improved. Notably, remarkable progress has been made in the diagnosis and treatment of childhood leukemia and lymphoma. Pediatric hematologists across hospitals at various levels have not only acquired comprehensive knowledge but also demonstrated high clinical proficiency. Many hospitals are now equipped with advanced technologies, such as precision medicine and genetic testing, which have substantially enhanced cure rates and survival outcomes for pediatric cancers.

In contrast, the development of diagnostic and therapeutic approaches for pediatric solid tumors has lagged behind. For instance, the introduction of GD2-targeted immunotherapy, a breakthrough in neuroblastoma treatment, occurred relatively late in China compared to high-income countries. Furthermore, standardized guidelines for pediatric solid tumors were only issued by the National Health Commission in 2019, marking a critical step toward improving care quality. In the same year, the National Center for Pediatric Cancer Surveillance (NCPCS) was established under the approval of the National Health Commission. This nationwide, hospital-based surveillance system was designed to continuously collect data on childhood and adolescent cancer cases, providing a foundation for evidence-based policy-making and resource allocation [1].

However, despite these advancements, the distribution of medical resources in China remains uneven, and healthcare conditions in economically underdeveloped regions continue to lag behind [2]. China’s healthcare system follows a tiered diagnosis and treatment model, in which primary care institutions (such as community health centers and township clinics) are responsible for managing common and minor illnesses, while tertiary hospitals handle complex and severe cases. Although the government promotes a structured referral system, patients retain the freedom to choose hospitals directly, often bypassing primary care. In terms of pediatric oncology, specialized services are highly centralized in large tertiary hospitals located in economically developed regions. This leads to substantial disparities in access and quality of care for patients from underdeveloped areas. These areas, including western China, minority areas, and remote mountainous regions, face significant challenges in pediatric solid tumor care due to geographic isolation, economic constraints, cultural barriers, and limited healthcare infrastructure. Recent national data further highlight these disparities: the first National Pediatric Cancer Surveillance Annual Report of China (2021), which covered 389 surveillance sites across 31 provinces, reported that nearly half of childhood cancer cases were treated in just five economically developed regions—Beijing, Guangdong, Shanghai, Chongqing, and Jiangsu. The report also indicated that most other areas continued to lack sufficient and high-level pediatric oncology services, forcing many families to seek treatment in other provinces [1]. These findings underscore the urgent need for a deeper understanding of the current status and unmet needs in pediatric solid tumor diagnosis and treatment in resource-limited regions.

This study was aimed to investigate the current landscape of pediatric solid tumor care in economically underdeveloped regions by surveying clinicians specializing in this field. The survey covered key aspects, including clinicians’ diagnostic and treatment capabilities, hospital equipment and technological support, training and education needs, and perceived barriers to improving care quality. By collecting and analyzing these data, this study sought to provide a theoretical foundation and evidence-based insights to inform policy development and resource allocation, ultimately enhancing healthcare services for children with solid tumors in these underserved regions.

Methods

This study used a cross-sectional survey design to examine the proposed aims.

Subjects

The study targeted provinces ranked among the bottom fourteen in GDP according to the 2022 economic performance data of 31 provinces of China (excluding Hong Kong, Macao, and Taiwan). These provinces included Guizhou province, Inner Mongolia autonomous region, Guangxi Zhuang autonomous region, Shanxi province, Yunnan province, Xinjiang Uygur autonomous region, Heilongjiang province, Qinghai province, Gansu province, Liaoning province, Jilin province, Hainan province, Ningxia Hui autonomous region, and Tibet autonomous region. The distribution of included provinces is shown in Fig. 1 and number of participants from each province is shown in Supplementary File 1 Table 1. Survey participants were primarily clinicians from provincial (autonomous region/municipal) hospitals with departments specializing in pediatrics, pediatric surgery, or pediatric hematology-oncology that manage pediatric solid tumors. Inclusion criteria required participants to hold a licensed medical qualification certificate. Graduate students and intern clinicians were excluded from the study. Clinicians attending less than one pediatric solid tumor case per year were also excluded.

Fig. 1.

The distribution of provinces included in this study

Table 1.

Socio-demographic characteristics of clinicians

Characteristics	N	%
Gender
Male	151	58.30%
Female	108	41.70%
Title
Chief	57	22.01%
Associate chief	64	24.71%
Attending	96	37.07%
Resident	42	16.22%
Academic degree
Doctor’s degree	35	13.51%
Master’s degree	119	45.95%
Bachelor’s degree	105	40.54%
Department
Pediatric Surgery	75	28.96%
Pediatric General Surgery	54	20.85%
Pediatric Hematology	43	16.60%
Pediatrics	24	9.27%
Pediatrics Medical Oncology	23	8.88%
Pediatric Urology	20	7.72%
Pediatric Surgical Oncology	8	3.09%
Others	12	4.63%

Questionnaire

The questionnaire used in this study was specifically designed to assess clinicians’ knowledge, diagnostic and treatment capabilities, educational and training needs, and perceived barriers in managing pediatric solid tumors in economically underdeveloped regions of China. It was developed through a two-step process. First, we conducted a comprehensive literature review to identify current best practices and existing gaps in the management of pediatric solid tumors. This review helped to clarify common clinical challenges. Subsequently, we organized expert consultations with pediatric oncology specialists to further explore the key challenges and unmet needs in pediatric solid tumor care in China, drawing on relevant clinical guidelines. The questionnaire consisted of several sections, including clinicians’ demographic characteristics (e.g., gender, professional title, academic degree, and region), their self-reported knowledge regarding pediatric solid tumors such as theoretical knowledge, familiarity with clinical guidelines, and multidisciplinary team (MDT) models, and their capabilities in diagnosis and treatment, focusing on experience with various diagnostic and therapeutic approaches. Additionally, the questionnaire explored clinicians’ attitudes and needs toward pediatric solid tumor-related training, including training participation, focus areas, and perceived importance, as well as perceived barriers in improving their professional capabilities, such as infrastructure deficiencies, resource limitations, and institutional support. The complete questionnaire is available in Supplementary File 2.

Data collection

Before the formal distribution of the questionnaire, a pilot survey was conducted with 15 participants, and the questionnaire was revised based on their feedback. Then the formal questionnaire was distributed to participants through the Pediatric Oncology Committee of the Chinese Anti-Cancer Association, the Pediatric Oncology Committee of the Chinese Research Hospital Association, and the Oncology Group of the Pediatric Surgery Branch of the Chinese Medical Association by contacting the heads of related departments of member hospitals, who were responsible for further distributing it to the doctors in their departments. Anonymous questionnaires were distributed and collected using the online survey platform “Wenjuanxing” (www.wjx.cn). To prevent missing data, respondents were unable to submit the questionnaire unless all mandatory fields were completed. The survey was conducted between October and December 2024 and duplicate responses were removed based on IP addresses. Participants who were not clinicians were excluded from the analysis. This study received ethical approval from the Ethics Committee of Beijing Children’s Hospital, Capital Medical University.

Statistical analysis

Data were analyzed by JMP Pro 17. Number and percentage were used when performing descriptive analysis.

Results

A total of 285 questionnaires were collected.Adfter excluding 25 responses from clinicians attending less than one pediatric solid tumor case per year and one intern, 259 questionnaires were finally included in the analysis. The demographic characteristics of participating clinicians are shown in Table 1. Among the participants, 58.30% (n = 151) were male, while 41.70% (n = 108) were female. The median age was 39 with an interquartile range from 33 to 46. In terms of professional titles, 22.01% (n = 57) were chief, 24.71% (n = 64) were associate chief, 37.07% (n = 96) were attending, and 16.22% (n = 42) were resident. Regarding academic qualifications, 13.51% (n = 35) held a doctorate degree, 45.95% (n = 119) held a master’s degree, and 40.54% (n = 105) held a bachelor’s degree. The clinicians had a median of 11 years of experience in pediatrics, with an interquartile range of 5 to 19 years.

Clinicians’ self-reported knowledge toward pediatric solid tumors

Clinicians’ self-reported knowledge toward pediatric solid tumors are shown in Table 2. The results showed that clinicians from economically underdeveloped regions of China generally reported a relatively high level of self-reported knowledge and familiarity with pediatric solid tumors. Specifically, 69.5% of the respondents rated their knowledge of theoretical aspect aspects of pediatric solid tumors (Q1.1) as high(N = 134) or very high(N = 46). Familiarity with the MDT model(Q1.2) was similarly rated high or very high by most clinicians(51.35%, N = 133 and 15.83%, N = 41 respectively), and the vast majority(76.83%) recognized the MDT model(Q1.3) as extremely important for effective pediatric solid tumor care. Additionally, a significant proportion(68.34%, N = 177) reported high familiarity with the latest guidelines and theoretical knowledge relevant to their field(Q1.4).

Table 2.

Clinicians’ self-reported knowledge of pediatric solid tumors

Questions	Very high N(%)	High N(%)	Moderate N(%)	Low N(%)	Very low N(%)
Q1.1: Your level of knowledge regarding theoretical aspects of pediatric solid tumors (e.g., common types, clinical manifestations, laboratory tests, differential diagnosis, etc.)	46(17.76%)	134(51.74%)	69(26.64%)	9(3.47%)	1(0.39%)
Q1.2: Your level of familiarity with the multidisciplinary team (MDT) model for pediatric solid tumors, including which departments are involved and their respective responsibilities?	41(15.83%)	133(51.35%)	73(28.19%)	12(4.63%)	0(0.00%)
Q1.3: How important do you think it is to implement a multidisciplinary team (MDT) model for pediatric solid tumors?	199(76.83%)	58(22.39%)	1(0.39%)	1(0.39%)	0(0.00%)
Q1.4: Your level of familiarity with the latest guidelines and theoretical knowledge related to pediatric solid tumors in your field.	36(13.90%)	177(68.34%)	41(15.83%)	5(1.93%)	0(0.00%)

Clinicians’ capabilities of diagnosis and treatment of pediatric solid tumors

The survey results on the diagnosis and treatment capabilities for pediatric solid tumors are presented in Table 3. A majority of clinicians (59.07%, N = 153) attended to fewer than 10 pediatric solid tumor cases per year, while only a small proportion (5.79%, N = 15) reported attending to more than 50 cases annually(Q2.1). The most frequent type of pediatric solid tumor, according to clinicians’ reports, was neuroblastoma, followed by nephroblastoma, and teratoma ranks third (Supplementary File 1 Table 2).

Table 3.

The diagnosis and treatment capabilities of pediatric solid tumors

Questions		N	%
Q2.1: How often do you attend pediatric solid tumor cases (including both confirmed and suspected cases)?
More than 50 cases per year		15	5.79%
20–50 cases per year		39	15.06%
10–20 cases per year		52	20.08%
5–10 cases per year		72	27.80%
1–5 cases per year		81	31.27%
Q2.2: Does your hospital have the conditions for treating pediatric solid tumors?
Yes		239	92.28%
	(Chemotherapy)	226	94.56%
	(Radiotherapy)	105	43.93%
	(Bone marrow transplantation)	90	37.66%
	(Surgery)	220	92.05%
	(Targeted therapy)	112	46.86%
	(Immunotherapy)	105	43.93%
	(Interventional treatments, e.g., transarterial chemoembolization, transcatheter arterial embolization, radiofrequency ablation, microwave ablation)	96	40.17%
No		20	7.72%
Q2.3: Does your hospital established a multidisciplinary team (MDT) for pediatric solid tumors?
Yes		109	42.08%
No		119	45.95%
Not sure		31	11.97%

Regarding hospital treatment capabilities, 92.28% (N = 239) of clinicians indicated that their hospitals were equipped for treating pediatric solid tumors(Q2.2). Among these, 94.56% (N = 226) reported the availability of chemotherapy, and 92.05% (N = 220) reported the availability of surgical treatment. However, fewer than half of the clinicians reported access to radiotherapy (43.93%, N = 105), bone marrow transplantation (37.66%, N = 90), targeted therapy (46.86%, N = 112), immunotherapy (43.93%, N = 105), or interventional treatments (40.17%, N = 96) at their institutions. 42.08% (N = 109) clinicians reported having an MDT in their hospitals and 45.95% (N = 119) reported none (Q2.3).

Table 4 shows the questions answered by clinicians from hospitals equipped for pediatric solid tumor care (N = 239). A total of 222(92.89%) clinicians reported having provided treatment for pediatric solid tumor patients(Q2.4). Among them, 78 clinicians (35.14%) acknowledged cases where chemotherapy was administered solely based on clinical diagnosis, without confirmation from bone marrow aspiration or pathological biopsy(Q2.5). Within these 78 clinicians, 59 (75.64%) reported that such cases accounted for less than 25% of their total treated patients, 15 (19.23%) indicated a proportion of 25% and 50%, while 2 (2.56%) clinicians reported an incidence of 50% to 75%, and another 2 (2.56%) noted that these cases exceeded 75% of their treated patients.

Table 4.

Diagnosis and treatment capabilities of clinicians from hospitals equipped for pediatric solid tumor care(N = 239)

Questions		N	%
Q2.4: Have you ever provided treatment for pediatric solid tumor patients?
Yes		222	92.89%
No		17	7.11%
Q2.5: Is there a situation where pediatric solid tumor patients are treated with chemotherapy based solely on clinical diagnosis (without bone marrow aspiration or pathological biopsy)?
Yes	Proportion	78	35.14%
	(<25%)	59	75.64%
	(25%-50%)	15	19.23%
	(50%-75%)	2	2.56%
	(>75%)	2	2.56%
No		139	62.61%
Not sure		5	2.25%
Q2.6: Have you ever encountered pediatric solid tumor patients but did not provide treatment?
Yes	Reasons	152	68.47%
	(Diagnosis unclear, referral suggested)	47	30.92%
	(Diagnosis confirmed, but treatment guidelines unclear)	13	8.55%
	(Treatment conditions not available at your institution)	32	21.05%
	(Parents requested treatment at another hospital)	126	82.89%
	(Other)	10	6.58%
No		70	31.53%

Additionally, 68.47% (152/222) of clinicians encountered pediatric solid tumor patients but did not provide treatment(Q2.6). The primary reason reported was parental preference for treatment at another hospital (82.89%, N = 126), followed by unclear diagnosis therefore referral suggested(30.92%, N = 47), and limited treatment conditions at their institution(21.05%, N = 32).

Clinicians’ attitudes and needs toward pediatric solid tumors-related training

Clinicians’ attitudes and needs regarding training in the diagnosis and treatment of pediatric solid tumors are summarized in Table 5. Among the respondents, 49.03% (N = 127) agreed, while 28.19% (N = 73) disagreed, that they had received sufficient training in pediatric tumors(Q3.1). Additionally, 55.21% (N = 143) reported having participated in relevant training within the past year(Q3.2). Notably, 96.13% (N = 249) of participants expressed a very high or high need for further training in this field(Q3.3). The survey also highlighted significant demand for training across four key areas(Q3.4): standard clinical pathways and guideline updates (93.98%, N = 234), disease recognition (87.15%, N = 217), prevention and early screening (82.73%, N = 206), and latest research and clinical trials (82.33%, N = 205). Regarding sources for obtaining knowledge about pediatric solid tumors (Q3.5), library for searching literatures and case discussion within department were reported to be available to 91.12%(N = 236) and 82.24%(213) of the clinicians, respectively. Other notable sources include academic conferences (67.18%, N = 174), online resources (43.24%, N = 112), and in-hospital education and training (38.61%, N = 100), while international visits (6.56%, N = 17) were the least common source. Clinicians also expressed clear preferences for the methods of training and education on pediatric solid tumors (Q3.6). The most commonly preferred methods were online education, lectures, or training sessions, endorsed by 89.19% (N = 231) of clinicians. This was followed by further study at other hospitals (75.29%, N = 195), on-site domestic academic conferences (71.43%, N = 185), and communication with experts from other hospitals (69.88%, N = 181). Additionally, online case-based discussions were favored by 58.69% (N = 152), while 30.50% (N = 79) expressed interest in participating as visiting scholars.

Table 5.

Attitudes and needs towards learning the diagnosis and treatment knowledge of pediatric solid tumors

Questions	N	%
Q3.1:I have received sufficient training in pediatric solid tumors.
Strongly agree	19	7.34%
Agree	127	49.03%
Not sure	20	7.72%
Disagree	73	28.19%
Strongly disagree	20	7.72%
Q3.2: Have you participated in any training on pediatric solid tumors in the past year?
Yes	143	55.21%
No	116	44.79%
Q3.3: The degree of your need for training related to pediatric solid tumors
Very high	143	55.21%
High	106	40.93%
Not sure	6	2.32%
Low	2	0.77%
Very low	2	0.77%
Q3.4: In your opinion, the focus of pediatric solid tumor training should be on
Prevention/early screening	206	82.73%
Disease recognition (etiology, epidemiology, pathology, clinical presentation, diagnosis, and differential diagnosis)	217	87.15%
Standard clinical pathways/guideline updates (treatment, complication management, follow-up, prognosis)	234	93.98%
Latest research /important clinical trials	205	82.33%
Other	3	1.20%
Q3.5: The sources available for obtaining knowledge about pediatric solid tumors
Literature	236	91.12%
Case discussions within department	213	82.24%
In-hospital education and training	100	38.61%
Academic conferences	174	67.18%
International visits	17	6.56%
Online resources	112	43.24%
Other	2	0.77%
Q3.6: The methods of training/education on pediatric solid tumors that you expect
Online education, lectures, or training	231	89.19%
Further study at other hospitals	195	75.29%
On-site domestic academic conferences	185	71.43%
Communication with experts from other hospitals	181	69.88%
Online case-based discussions	152	58.69%
Visiting scholar	79	30.50%
Other	2	0.77%

Clinicians’ perceived barrier in improving pediatric solid tumors-related capabilities

The survey identified several key barriers faced by clinicians in the diagnosis and treatment of pediatric solid tumors, shown in Table 6. The most reported barriers were lack of sufficient policy support and financial investment for pediatric solid tumor-related departments (67.57%, N = 175), and lack of diagnostic and treatment protocols and quality control standards (44.79%, N = 116).

Table 6.

Perceived barriers for improving diagnostic and treatment capability for pediatric solid tumors

Questions	N	%
Q4.1: What difficulties do you think you are facing in the diagnosis and treatment of pediatric solid tumors?
Lack of sufficient policy support and financial investment for pediatric solid tumor-related departments in your hospital	175	67.57%
Lack of pediatric solid tumor-related diagnostic and treatment protocols and quality control standards in your hospital	116	44.79%
Lack of necessary medical equipment/instruments related to solid tumors in your hospital (equipment shortage)	106	40.93%
Lack of necessary diagnostic, testing, and pathological capabilities for solid tumors in your hospital	92	35.52%
Lack of surgical department collaboration in your hospital, unable to perform surgery after chemotherapy or radiotherapy	56	21.62%
Lack of internal medicine department collaboration in your hospital, unable to perform chemotherapy after surgery	44	16.99%
Lack of medical technology department collaboration in your hospital, unable to perform radiotherapy after surgery	82	31.66%
Lack of effective drugs for treating pediatric solid tumors in your hospital (e.g., drugs for autologous stem cell transplant conditioning like mafosfamide, GD2 antibodies, etc.)	100	38.61%
Few pediatric solid tumor patients in your hospital, insufficient clinical experience	96	37.07%
Lack of training and learning opportunities related to pediatric solid tumors	86	33.20%
Heavy clinical workload for other diseases, lacking time for in-depth study	68	26.25%
Other	4	1.54%
None of the above	12	4.63%

Discussions

In this study, we investigate the diagnostic and treatment practices, training and education needs, and perceived barriers to improving pediatric solid tumor care in 14 economically underdeveloped provinces of China, based on a survey of clinicians in these regions. To the best of our knowledge, this is the first comprehensive overview of the current state of pediatric solid tumor diagnosis and treatment in these areas. The findings reveal that many clinicians work in settings with constrained diagnostic and treatment capacities. Although they self-reported a relatively good level of knowledge and awareness regarding pediatric solid tumors, most had limited clinical experience and at times engaged in practices that deviate from established clinical guidelines, highlighting gaps between perceived knowledge and practical competency. The study also underscores a strong demand for targeted training among clinicians, focusing on early screening, accurate diagnosis, clinical guidelines, as well as the latest research. Insufficient policy support and financial investment are identified as the primary barriers to enhancing pediatric solid tumor care in these regions.

The unequal distribution of healthcare services for children, both internationally and within countries, is a widespread issue, particularly in low- and middle-income countries (LMICs) where resources are even more limited [3, 4]. A study reported that over 65% of cancer-related deaths occur in LMICs, but only 5% of global health resources directed toward cancer are spent there [5]. In China, previous research has highlighted significant disparities in the geographic distribution of general pediatric care [6, 7]. Pediatricians with advanced education and those working in well-equipped tertiary hospitals tend to be concentrated in more developed regions, resulting in a higher capacity for diagnosis and treatment in those areas. This disparity is particularly pronounced in the diagnosis and treatment of pediatric solid tumors, which require more advanced diagnostic tools, specialized treatment modalities, and multidisciplinary care [8, 9]. These demands make the management of such diseases particularly sensitive to resource limitations. The absence or inadequacy of critical components such as precise imaging, pathology services, and access to surgical, chemotherapeutic, and sometimes radiotherapeutic interventions makes it significantly more challenging to provide timely and effective care for children with solid tumors.

The issue of limited experience among clinicians in managing pediatric solid tumors, as highlighted in the survey where over half of the clinicians reported to manage fewer than 10 such cases annually, is a significant concern for healthcare systems, particularly in resource-limited settings. One study conducted by Rodriguez-Galindo et al. highlights the impact of healthcare infrastructure limitations in LMICs on pediatric cancer treatment [10]. They found that in many regions, healthcare providers were managing very few pediatric cancer cases annually due to both financial constraints and a shortage of skilled professionals. Moreover, a significant proportion of clinicians in this survey encountered pediatric solid tumor cases but did not provide treatment, the primary reason of which was parental preference for seeking care at other hospitals. A systematic review by Magrath et al. discusses how parental preference for seeking treatment at more established hospitals—often in wealthier areas—reflects a broader issue of trust in local healthcare services. This phenomenon is commonly observed in LMICs, where perceptions of substandard care, often due to insufficient medical resources, deter families from utilizing local services. As a result, local clinicians face a diminished case volume, limiting their opportunities to develop specialized skills. This lack of experience can perpetuate mistrust among families and patients, further exacerbating the issue [11]. A comment by Murray et al. noted that the provision of high-quality cancer care depends not only on clinical expertise but also on patients’ trust and engagement [12]. Without enough cases to build experience, local hospitals struggle to develop the necessary infrastructure, perpetuating the cycle of inadequate care.

A notable proportion of respondents reported initiating chemotherapy based solely on clinical diagnosis without histopathological confirmation. While our study did not directly investigate the underlying reasons for this practice, it likely reflects the limitations in diagnostic infrastructure and specialized pathology services in under-resourced regions. In particular, access to pediatric oncology pathologists remains scarce in many areas [2], and delays in obtaining biopsy results may prompt clinicians to initiate empirical treatment when malignancy is strongly suspected. Additionally, insufficient training in tumor-specific diagnostic protocols and biopsy techniques may contribute to this deviation from standard practice. This highlights a critical gap in the diagnostic pathway, as accurate pathological confirmation is essential for appropriate risk stratification and treatment planning. In line with findings from other LMICs, limited capacity for biological tumor characterization hampers risk-adapted therapy, potentially leading to overtreatment and increasing the risk of treatment abandonment [13, 14].

To address the multifaceted challenges identified, we propose a three-tiered conceptual model integrating interventions at individual, institutional, and national levels. This approach aligns not only with the World Health Organization’s framework for strengthening health systems—through workforce development, service delivery optimization, and governance restructuring, particularly in resource-constrained settings [15]—but also with the WHO Global Initiative for Childhood Cancer (GICC) and its CUREALL framework [16]. The CUREALL strategy outlines seven essential components (Centers of excellence, Universal health coverage, Regimens, Evaluation, Advocacy, Linkage, and Leadership) that collectively aim to improve childhood cancer outcomes systematically. Our model operationalizes these components across tiers, facilitating targeted, context-appropriate interventions in low-resource settings. The interdependence of these levels reflects the complex systemic nature of pediatric oncology care, where isolated interventions often fail to create sustainable change [17].

At the individual level, capacity building and standardized training among clinicians are critical. While 55.21% of respondents in our survey reported receiving pediatric oncology training in the past year, nearly half felt inadequately prepared, and 96.13% expressed a strong demand for further education. Traditional didactic methods may be insufficient, especially given the low patient volumes observed. Simulation-based learning and tele-mentoring platforms, such as Project ECHO, have demonstrated significant improvements in clinician competency [18], aligning with the Regimens (R) component of CUREALL. Moreover, adherence to international standardized guidelines, such as surgical guidelines for treating children with Wilms tumor in low-resource settings [19, 20], is essential to reduce variability in treatment and improve survival rates. Experience from upper-middle-income countries (UMICs) like Turkey further the benefit of risk-adapted chemotherapy protocols in enhancing patient outcomes [21]. In addition, supportive care is also a critical component of pediatric oncology that should be strengthened, especially in settings where curative treatment options are limited. When malignancies progress after one or two lines of chemotherapy and repetitive administration of conventional chemotherapy at the maximum tolerated dose imposes many adverse effects, best supportive care—encompassing pain management in accordance with WHO guidelines, blood transfusions, infection control, and the management of malodorous necrotic tumors—is often the only available option [22].

At the institutional level, healthcare facilities must act as hubs of multidisciplinary collaboration and service integration. Establishing multidisciplinary tumor boards enhances clinical decision-making [23], aligning with the Centers of excellence (C) component of CUREALL. For example, Turkey achieved a remarkable improvement in survival rates for rhabdomyosarcoma by integrating surgical, radiotherapeutic, and chemotherapeutic expertise [21]. Institutions should also centralize diagnostic and treatment services to maximize limited resources, following models such as Brazil’s diagnostic hubs, which improved access to radiotherapy and surgical services [13]. Strengthening referral pathways and implementing hospital-based monitoring systems are essential to ensure care continuity and enable data-driven evaluation—core to the Linkage (L) and Evaluation (E) domains of the CUREALL framework. Egyptian hospitals, for instance, improved treatment adherence significantly through structured referral protocols and outcome monitoring systems.

At the national level, systemic support is the cornerstone of improving pediatric oncology care in low-resource settings. Policymakers must recognize that sharpening the technical expertise of surgeons alone is insufficient to overcome infrastructural deficits. As highlighted by Bickler et al., pediatric surgical oncology can be a cost-effective investment that elevates overall regional health service quality [24]. Governments should prioritize equitable investment in essential infrastructure such as radiotherapy units and pathology laboratories—still lacking in many African and Asian countries, according to the International Atomic Energy Agency (IAEA) [25–27]—as part of realizing universal coverage (U of the CUREALL framework). Additionally, national strategies should address the workforce gap through financial incentives, such as loan forgiveness programs and rural service incentives, to attract and retain pediatric oncology specialists. Evidence shows that such financial-incentive programs had placed substantial numbers of health workers in underserved areas and that program participants are more likely than non-participants to work in underserved areas in the long run [28].

Several limitations should be considered when interpreting the findings. First, the classification of “economically underdeveloped” regions was based solely on provincial GDP rankings, which does not account for intra-provincial disparities such as rural-urban differences or per capita healthcare spending, which may limit the generalizability of the findings. Second, the study relied entirely on self-reported data, which is subject to recall and social desirability bias—especially for sensitive items such as administering chemotherapy without confirmed pathology. Future studies using mixed methods, including chart reviews or qualitative interviews, would help validate and enrich these findings. Third, while the questionnaire was developed through expert consultation and literature review, it was not subjected to formal psychometric validation, and internal consistency was not assessed. Fourth, the term “multidisciplinary team (MDT)” was not explicitly defined in the questionnaire, which may have led to varied interpretations among respondents. Finally, the absence of objective measures such as clinical outcomes or hospital infrastructure data limits the depth of analysis. Despite these limitations, this study offers the first large-scale, multi-center assessment of pediatric solid tumor diagnostic and treatment capacity across under-resourced regions of China.

Our findings provide critical baseline data on shared systemic challenges—such as insufficient diagnostic infrastructure, unmet training needs, and fragmented policy support—that transcend provincial heterogeneity. The identification of common barriers such as low case volumes limiting clinical expertise, parental preference for centralized care, and financial constraints, underscores universal priorities for intervention, even amidst regional variations.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

X.W., S.Y., Q.Z. and Q.R. contributed equally to this work, including conceptualization, study design, data analysis, and manuscript drafting. H.Q., W.Y., H.C., X.C., and Z.Z. were responsible for data collection, processing, and preliminary analysis. S.C. performed statistical analysis and data interpretation. H.W. and S.C. supervised the study, provided critical revisions to the manuscript, and contributed to the interpretation of findings. H.W. also oversaw project administration and coordination. All authors reviewed and approved the final manuscript.

Funding

This study was funded by Capital's Funds for Health Improvement and Research (CFH) (No. 2024-1-2091) and Noncommunicable Chronic Diseases-National Science and Technology Major Project (2024ZD0519906).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved by Institutional Review Board of Beijing Children’s Hospital. All participants provided informed consent before completing the survey. Participation was voluntary, and responses were anonymized to ensure confidentiality. The study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.